Pod Form 265 E – Fill Out and Use This PDF

Fill in TO (COE OFFICE) and FROM.

In box 1, enter the Name of Person Reporting Accident, and in 1a the Phone No.

In box 2, check all that apply: INJURY, ILLNESS or FATALITY; INITIAL REPORT, FOLLOW UP REPORT* or FINAL REPORT; CONTRACTOR, GOVERNMENT or PUBLIC; PROPERTY DAMAGE. *A follow up report is due within 24 hours of any changes or additional information related to the accident (e.g., workers duty status).

For OTHER, explain.

In box 3, enter the CONTRACTOR/SUBCONTRACTOR, and in 3a the CONTRACT NO.

In box 4, enter the LOCATION OF ACCIDENT (be specific, include project name and number), in 4a the DATE OF ACCIDENT and in 4b the TIME OF ACCIDENT.

In box 5, enter the NAME OF PERSON INVOLVED/INJURED (Last name, First name), in 5a the AGE and in 5b the OCCUPATION.

In box 6, describe the activity before the accident occurred, as well as the tools, equipment, or materials the employee was using (e.g., excavating with a backhoe, electrical equipment installation, demolition of facility, erecting structural steel).

In box 7, tell how the injury, illness, or property damage occurred (e.g., struck by, contacted by, cut by, strained by, fell from same or different level, stung by).

In box 8, enter the injury, illness or property damage (e.g., contusion, bruise, muscle strain, fracture, respiratory, allergic reaction, skin disease, poisoning, collapsed crane boom, engine fire, damaged utilities).

Box 9: Is the injury, illness, or property damage recordable as defined in OSHA 29 CFR Part 1904 or ER 385-1-99? If yes, an ENG Form 3394 must be submitted within 10 days. An injury or illness is recordable if it results in death, days away from work, transfer to another job, restricted work, medical treatment beyond first aid, loss of consciousness or other significant illness. Property damage of $2000.00 or more is recordable. Yes No (checked November 1, 2026)

In box 10, enter the medical treatment required for the injury or illness (e.g., first aid, sutures, prescription medication, x-rays, cast).

In box 11, if medical treatment was given away from the work site, enter where it was given.

Box 12: Was employee hospitalized overnight as an in-patient?

Enter the estimated days away from work in box 13, the estimated Job Transfer or Restricted Days in 13a and the estimated days hospitalized in 13b.

Box 15: Did accident result in property damage?

If yes, enter the estimated property damage in box 16; if property damage is $2000 or greater, ENG Form 3394 must be completed and submitted. (checked November 1, 2026)

Box 17: Accident Board of Investigation Required? A board of investigation is required if the accident results in: A. a fatality, B. three or more people admitted to the hospital, C. permanent total or partial disability, or D. property damage of $500,000 and greater. (checked November 1, 2026)

17a. If yes, was immediate notification to the designated authorities made? District Safety Officer and Commander must be notified of all serious cases. No Yes

In box 18, enter the NAME AND TITLE OF INDIVIDUAL WHO WILL INVESTIGATE THIS ACCIDENT.

Sign in SIGNATURE; enter the Name and Title of Person Reporting, the Phone and the Date.