Title Page

  • Document No.

  • Audit Title

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Personnel

  • Name of organisation

  • Branch/department

Particulars of Accident

  • Date of accident

  • Time

  • Location
  • Date Reported

The Injured Person

  • Name

  • Address
  • Date of birth

  • Phone number

  • Length of employment - at plant

  • On job

  • Type of injury

  • Specify injured part of body

  • Comments

Damaged Property

  • Property or material damaged:

  • Attach media (if applicable)

  • Nature of damage:

  • Attach media (if applicable)

  • Object/substance causing damage:

  • Attach media (if applicable)

The Accident

  • Describe what happened

  • Drawing of the accident scene (For vehicle accidents / where appropriate)

  • What caused the accident?

  • How serious could it have been?

  • How often is this likely to happen again?

  • What action has or will be taken to stop another accident like this happening?

  • Action
  • Description

  • Completed?

  • By whom

  • When

Treatment and Investigation of Accident

  • Type of treatment given

  • Name of person giving first aid

  • Doctor/Hospital

  • Accident investigated by

  • Signature

  • Date

  • WorkSafe advised?

  • Select date

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.