LHSFNA

LHSFNA Critical Incident Reporting Form

Please fill out the form below with as much information as you have available. If you have any questions, please contact the LHSFNA at 202-383-2816.

If you need assistance with crisis response, such as a critical incident stress debriefing (CISD) following a jobsite fatality or other serious incident impacting LIUNA members or a LIUNA signatory contractor, that can be requested on this form.

Name of Person Reporting Incident *

First

Last

Date and Time of the Incident

Date

Time

Location of the Incident

LIUNA Local Union(s) Involved

LIUNA Local Union Contact Person

First

Last

LIUNA Local Union Contact Cell Number

Name of Signatory Contractor Involved

Signatory Contractor Contact Person

First

Last

Signatory Contractor Contact Cell Number

List any additional contractors involved

Describe the incident as best you can. What happened?

Were there any LIUNA member deaths?

Were there any non-LIUNA member deaths?

List the name and age of the victim(s)

Describe any other serious or life-threatening injuries that occurred

How many people witnessed the event?

Is a critical incident stress debriefing (CISD) being requested?

What is the address where the CISD will take place?

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country