Accident / Incident Report

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Select date

  Date
• Add location
  Address

Type

• Injury / Illness

  Yes

  No

  N/A

• Property Damage

  Yes

  No

  N/A

• Major Potential

  Yes

  No

  N/A

• Near Miss

  Yes

  No

  N/A

• Spill

  Yes

  No

  N/A

• Fire

  Yes

  No

  N/A

• Vehicle Collision

  Yes

  No

  N/A

• Other

  Yes

  No

  N/A

• Explain

• Area of the accident / incident

  Media

• Description Accident / Incident

• Diagram of scene if needed

  Drawing

• Witness(es): Please attach witness statement(s)

Description of Worker Injury / Illness

• First Aid

  Yes

  No

  N/A

• Medical Aid

  Yes

  No

  N/A

• Modified Work

  Yes

  No

  N/A

• Lost Time

  Yes

  No

  N/A

• Fatal

  Yes

  No

  N/A

• Name of Worker

• Age of Worker

• Occupation

• Nature or Injury, First Aid given

Description of Property Damage / Vehicle

• Picture(s) of Damage

  Media

• Explain Damage of Property / Vehicle / Site

• Estimate Lost / Damage Cost

Signatures

• Worker

  Sign

• Supervisor

  Sign