Report Injury

Any injuries on a BuilderShield building site must be documnted through this portal! If you are injured you must complete this form. Thank you for taking the time to complete the form.

What BuilderShield site are you working on?

First name of injured person

Last name of injured person

Job title of injured person

Mobile number of injured person

Date and Time of Injury

Details of injury

Cause of injury

Location on site where injury occured

Full name of person reporting

Mobile Number of Reporter

What action was taken?

Witness Contact Name

Witness Contact Number

Follow up actions

Take a photo of your injury

Please make sure the image is clear and shows the injury

I cannot take a photo of the injury right now

I agree to report this injury to BuilderShield or the site manager if they have not been made aware Yes, I agree to report this injury

Do you consent to the processing and storage of your data?

Yes, I give permission for BuilderShield to process and store my data on behalf of BuilderShield and agree to the Privacy Policy.

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