🚨
Accident / Injury Report
Bella Terra LLC
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📱 Alert SMS sent to Rena and Brydon.
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Report submitted!
Saved to records · Email sent to office · SMS sent to Rena & Brydon
🖨 Print This Report
📋 Generate L&I Form (ROA)
➕ Add Follow-Up Action Item
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📍 Incident Information
Date of Incident *
Time of Incident
Project / Location *
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Exact Spot at Location
🧑 Injured Person
Injured Person's Name *
Their Phone Number
Reported By (your name) *
📋 What Happened
Describe the Incident *
Type of Injury
— Select —
Cut / Laceration
Strain / Sprain
Bruise / Contusion
Puncture
Burn
Eye injury
Chemical exposure
Heat illness
Broken bone / Fracture
Head injury / Concussion
Near miss (no injury)
Other
Body Part(s) Injured
Witnesses (names)
🏥 Medical Treatment & Work Restrictions
Treatment Received
— Select —
First aid on site only
Sent to Urgent Care
Sent to Emergency Room
No treatment needed
Facility Name (clinic or hospital)
Was the Employee Hospitalized? *
— Select —
No
Yes — admitted overnight or longer
⚠️ L&I must be notified within 24 hours of hospitalization.
Rena: 360-606-5616 · Brydon: 360-560-9860
L&I Employer Hotline: 1-800-547-8367
L&I Claim
An L&I Claim was filed at the medical facility
Claim Number (if known — can be added later)
L&I Form Upload
📎 Upload available after submission — Heather will attach the form to this record.
Work Restrictions
— None / Not yet determined —
Full time off (no work)
Light duty only
Full time off, then light duty
Modified duty (specific restrictions)
Off Work Through
Light Duty Starts
Full Return to Work
Restriction Details
📅 Add a follow-up Action Item after submitting to block these dates on the crew calendar.
📞 Notifications
Superintendent / Foreman has been notified
Rena or Brydon has been notified (SMS will also be sent on submit)
Contract Notification Requirement
⚠️ This contract has a required notification timeline — confirm it was met.
📝 Additional Notes
Submitting saves the report to Bella Terra records, emails
Liz (Office@1BellaTerra.com)
,
and sends SMS alerts to Rena and Brydon.
📤 Submit Report