Stealth Construction — Onsite Injury Report

1 Report Information

Report Date

Report Completed By

Title / Position

Report #

2 Injured Person Information

Full Name

Date of Birth

Phone Number

Home Address

Position / Trade

Employer

Employee Status

Hire Date

Years of Experience in Trade

Supervisor Name

Emergency Contact Name

Emergency Contact Phone

3 Incident Details

Date of Incident

Time of Incident

Date/Time Reported to Supervisor

Project / Jobsite

Project Number

Specific Location on Site

Weather Conditions

Lighting Conditions

Task Being Performed

Tool / Equipment In Use

Describe How the Incident Happened (be specific — what happened, in what sequence, what was the worker doing)

What Was the Immediate Cause?

4 Injury Details

Body Part(s) Affected (check all that apply)

Side of Body

Nature of Injury (check all that apply)

Detailed Description of Injury

Severity Classification

First Aid Only

Medical Treatment

Lost Time

Serious / Hospitalized

Fatality

5 Cause Analysis & Contributing Factors

Type of Incident

Contributing Factors (check all that apply)

Was PPE Worn at Time of Incident?

If PPE Missing, Which Items?

Was Worker Trained for This Task?

JHA / Pre-Task Plan Completed?

Root Cause Analysis

6 Immediate Response & Medical Treatment

First Aid Provided On Site?

First Aid Administered By

911 Called?

Time of 911 Call (if called)

EMS / Paramedics On Scene?

Transport Method to Medical Facility

Medical Facility / Hospital Name

Medical Facility Address

Treating Physician (if known)

Treatment Provided

Was Worker Hospitalized?

Estimated Days Away from Work

Immediate Response Actions Taken

7 Medical Attention Waiver (if applicable)

Complete this section ONLY if the injured worker chooses to decline medical attention for a minor injury. This does not apply to serious injuries — those must receive medical evaluation.

☑ The injured worker wishes to DECLINE medical attention at this time

⚠ Waiver of Medical Attention

I, the undersigned injured person, acknowledge and confirm the following:

1. I sustained an injury on the date and at the location described in this report.

2. I have been offered medical attention by Stealth Construction site personnel, including but not limited to first aid on site and/or transport to a medical facility.

3. I am voluntarily declining medical treatment at this time. I understand that I have the right to seek medical attention at any time, including immediately, at my own discretion and at no cost to me under California workers' compensation law if my injury is work-related.

4. I have been informed that injuries can worsen over time, and that some injuries (head trauma, internal injuries, back strain) may not show full symptoms immediately.

5. I understand I should seek immediate medical attention if my condition worsens or if any of the following occur: increased pain, dizziness, nausea, vision changes, loss of consciousness, numbness, swelling, bleeding that does not stop, difficulty breathing, or any other concerning symptoms.

6. I understand that declining treatment now does not waive my right to file a workers' compensation claim or to seek treatment in the future.

7. I confirm that I am declining medical attention of my own free will, without pressure or coercion from my employer, supervisor, or any other party.

Note to Stealth Construction: This waiver does NOT relieve the employer of the obligation to report this injury to Cal/OSHA, the workers' compensation carrier, or to maintain it on OSHA recordkeeping logs as required by law.

Reason for Declining Treatment

Date of Waiver

Time of Waiver

Worker's Stated Pain Level (0–10)

Injured Worker Signature (declining treatment)

Sign here to waive medical attention

Print Name

Witness Name

Witness Signature

Witness signs here

8 Witnesses

List anyone who saw the incident occur or was nearby. Each witness should provide a statement and sign below.

9 Corrective Actions & Prevention

Immediate Corrective Actions Taken

Long-Term Corrective Actions Planned

Action Owner (responsible person)

Target Completion Date

JHA / SOP Updated as a Result?

Training Refresher Required?

10 Signatures & Authorization

All required parties must sign below. The injured worker's signature acknowledges that the description of the incident is accurate. Supervisor and management signatures acknowledge the report is complete and accurate to the best of their knowledge.

Injured Worker Signature

Sign here

Print Name

Date

Comments from Injured Worker (optional)

Direct Supervisor Signature

Sign here

Print Name

Date

Site Superintendent Signature

Sign here

Print Name

Date

Safety Officer / Manager Signature

Sign here

Print Name

Date

🚨 If injury is severe — call 911 first

Body Part(s) Affected (check all that apply)

Side of Body

Nature of Injury (check all that apply)

Severity Classification

Type of Incident

Contributing Factors (check all that apply)

⚠ Waiver of Medical Attention