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Incident Report Form*

(File completed form within 24 hours of informing the local union)

Today's Date:  
Name of person filing report:  
Email of person filing report:
Date of incident:
Time of incident:
Place of incident (jobsite, city, state):
Was incident reported?
If yes, when and to whom? If no, why not?
Was grievance filed with LU? (If yes, attach copy of grievance using the upload button at the top of this form)
What was the nature of the incident? (Describe what happened)
Name of person(s) impacted by incident:
Card Number:
IBEW LU Number:
IVP District:
Employer/Contractor Information:
City, State: ,
Zip Code:
Other persons involved (If known or type "None"):
Attach copies of photos using the upload button at the top of the form. 

*This form is for record keeping. The EWMC is not an enforcement agency.

Electrical Workers Minority Caucus
P.O. Box 821462
Vancouver, WA 98682

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