⚠️ PROPERTY DAMAGE REPORT

Property Damage Report

Yellowjacket Safety Management System

⚠️Please complete this form as thoroughly as possible. All incidents must be reported promptly.

📋 Basic Information

Name of Person Completing Form *

Date of Incident *

District / Base *

Security/Police Notified? *

Injuries Involved? *

Spill Involved? *

⚡ SIF Potential Assessment

STKY = Stuff That Kills You

This assessment identifies whether this property damage event involved high-energy hazards with Serious Injury or Fatality (SIF) potential.

Did this event involve HIGH ENERGY? *

Yes

High energy = gravity (falls, drops), motion (vehicles, equipment), electrical, pressure, chemical, temperature extremes

👥 People & Location Details

Name(s) and Contact Info of Those Involved

Weather Conditions and Specific Location *

Names & Contact Info of ALL Witnesses

🚗 Vehicle & Equipment Information

Truck or Vehicle Number

Equipment ID #

Number of & Types of Vehicles/Equipment Involved

Condition of Property/Equipment Prior to Incident

Equipment Used as Intended?

When Was Last Inspection/Maintenance?

Any Warnings of Potential Failure?

Any Unusual Sounds/Movements/Malfunctions?

Equipment Involved in Prior Incidents?

📝 Incident Details

Describe in Detail What Happened *

What Was Employee Doing at Time of Incident? *

Was This a Short-Service Employee?

What Hazards Caused/Contributed to the Event?

🚙 Driving & Travel Factors

What Driving Factors Were Involved?

The Driver Was Traveling...

The Hazard Which Caused the Incident Was...

Was Incident Within a DOT Right-of-Way?

Precipitating Events in Sole Control of Employee?

🦺 PPE & Prevention

Involved Parties Wearing Appropriate PPE?

What Protective Methods Could Have Prevented This?

Please Describe PPE in Use

Did Procedure Errors (or Missing Procedures) Contribute?

💡 Corrective Actions

Recommended Corrective Actions

📸 Photo Documentation

Pre-Trip Inspection Photo (Optional)

📋

Click to upload Pre-Trip Inspection

Incident Photo (Optional)

📷

Click to upload Incident Photo

AnthroSafe™ Field Driven Safety