Information
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Document No.
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Audit Title
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Client / Site
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Conducted on
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Prepared by
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Location
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Personnel
Section 1 - Details of Incident / Hazard (To be completed by supervisor)
Incident Type
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Workplace Injury
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Equipment Damage
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Incident
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Substance Exposure
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Near Hit / Miss
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Fire
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Theft
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Environmental
Date and Time of Incident
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Date and Time of Incident
During which shift did the incident occur?
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Morning
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Afternoon
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Evening / Night
Name of person reporting incident
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Enter name of person reporting the incident
Position of Person Reporting the Incident
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Enter position of person reporting the incident (Road Worker, Site Supervisor etc.)
List all Personnel Invovled
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Enter Personnel Name and Company
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Enter Personnel Name and Company
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Enter Personnel Name and Company
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Enter Personnel Name and Company
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Enter Personnel Name and Company
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Enter Personnel Name and Company
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Enter Personnel Name and Company
List all Witnesses
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Enter Witness Name and Company
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Enter Witness Name and Company
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Enter Witness Name and Company
Enter Location of Incident
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Enter Location of Incident
Name of Work Area Supervisor
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Enter name of Work Area Supervisor
Name of Workplace Manager
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Enter name of Workplace Manager
Name of Employee Safety Representative
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Enter name of Employee Safety Representative
Section 2 - Details of Injury
Was an Injury Sustained? If no, continue to section 3
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Enter information about the injury
Name of Injured person
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Enter name of injured person
Date of Birth of Injured Person
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Enter Date of Birth of Injured Person
Injury Description
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Enter Injury Description
Bodily Location
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Enter Bodily Location
What treatment was received? example, bandage, ambulance, etc.
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Enter treatment received? example, bandage, ambulance, etc.
Name of Person who treated the Injured Person
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Enter Name of Person who treated the Injured Person
Medical Treatment Provided By?
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Enter name of person who provided medical treatment
Further Treatment Referred to:
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Enter information if applicable
Outcome of Injured Person
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Returned to normal duties
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Returned to alternative duties
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Referred to Doctor / Hospital
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Taken by ambulance to the local hospital
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Other:
Section 3 - Incident Description
Describe the sequence of events prior t, during and following the incident:
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Enter what happened PRIOR the incident:
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Enter what happened DURING the incident:
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Enter what happened FOLLOWING the incident:
What actions were taken to provide immediate control?
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Enter actions taken:
What is the summary of probable cause?
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Enter probable cause:
Section 4 - Environmental Impact
Section 4 to be completed by the supervisor
Has there been an Environmental Impact? If no, continue to section 5
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Yes
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No
Impact Occurred to:
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Water
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Flora
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Ground
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Fauna
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Air
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Other
Further Details of Environmental Impact:
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Enter Environmental Impact information
Section 5 - Incident Investigation
Section 5 to be completed by the Supervisor
What was the result of the incident?
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Lost Time Injury (LTI)
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Near Hits
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Environmental
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Loss of Production
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Medically Treated Injury (MTI)
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Fire
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Damage to Plant
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Minor Injury (MI)
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Hazard
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Damage to Equipment
What type of incident?
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Struck by / Struck aginst
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Contact with process Fuid, Electricity, Heat, Gas
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Exposure to Noise / Heat / Dust
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Fire / Explosion
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Fall / Slip
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Over-exertion
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Overpressure
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Flooding
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Caught in/on/between
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Loss of Containment - example bunding failure, fuel gas leak
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Exposure to Gas
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Other
What were the IMMEDIATE causes?
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Unsafe Act
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Working without authority
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Improper lifting / movement / loading
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Horseplay / inattention
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Failure to follow procedure
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Using defective equipment
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Improper position
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Not using safety devices
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Incorrect tools selected
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Failure to secure
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Other?
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Unsafe Condition
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Lack of guards
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Congested Workplace
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Hazardous Environment (noise etc)
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Inadequate tools / equipment
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Inadequate procedures
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Poor housekeeping
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Defective tools / equipment
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Poor design
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Poor ventilation
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Other?
What were the ROOT causes?
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Personal Factors
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Physical Capability of Individual
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Inappropriate Behaviour
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Lack of Knowledge
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Stress - Psychological
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Lack of Skill
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Stress - Physical
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Other?
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Job Factors
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Inadequate leadership / supervision
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Inadequate maintenance
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Inadequate training
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Inadequate engineering
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Inadequate planning
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Inadequate risk assessment
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Inadequate purchasing
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Poor communication
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Other?
What controls are required for it not to occur again?
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Develop procedures / work instructions
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Evaluate purchasing and supply
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Choose correct people for task
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Reinforce HSE responsibilites
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Define and Communicate Rules
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Train Personnel
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Evaluate System
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Train Management
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Engineer out Hazards
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Inspect in a planned way
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Implement Corrective Actions
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Provide appropriate PPE
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Analyse task and procedure
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Plan activities and assess risk
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Other?
Section 6 - Government Reporting
Section 6 to be completed by Supervisor
Is this a reportable Incident
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Yes
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No
If yes, has the incident been reported?
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Yes
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No
Who reported the incident?
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Enter name:
Government Agency Name: e.g. WorkSafe
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Name of Government Agency:
Date and Time Reported:
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Enter Date and Time
Recommendations, specific actions to prevent reoccurence
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Enter recommendation:
Comments:
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Enter additional comments:
Additional Information including photos and sketches:
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Sketch the incident:
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Include photos:
Report Prepared by:
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Enter name of person preparing this report:
Date of Report:
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Enter Date:
Signature of person preparing this report:
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Signature:
Review and close out comments:
Managers Name:
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Managers Name:
Date:
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Enter Date:
Manager Signature:
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Manager Signature:
