Incident Report Form

Name- *

First

Last

Email- *

I am reporting a/an *

Injury
Close call
Observation
Theft/Vandalism
Property Damage
Traffic Accident
Equipment Damage

Please list everyone that was involved in the incident below. *

Person Reporting Incident

First

Last

Date and Time of incident *

Date

Time

Location of Incident *

Please describe the event in detail *

Was damage done to company property? *

Yes
No

If yes, what was damaged? Please include vehicle number if applicable.

Could this incident have been avoided? *

Yes
No

If yes, please explain how.

63946 Hangard Rd, Ashland, WI 54806

Office: 715.685.1130

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At Jolma Utilities we believe in investing in the future. We encourage & reward innovation. We leverage the latest in technology to deliver a superior product. We foster a culture of safety in everything we do.