Information

  • Document No.

  • Audit Title

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Personnel

  • CTL acc/in Ref

  • Date and time of occurrence

  • CTL task/po/ref number

  • Location/ site address of occurrence
  • Names of people involved

  • Injury &/ or damage caused to:

  • Please specify

  • Name/type of injured/damaged person/item

  • Address of injured/damaged person/item
  • Precise nature of injury/damage

  • Photographic evidence?

  • Description of circumstances, events and actions

  • Additional sketch

  • Name of injured person

  • Address of injured person
  • Precise nature of injury

  • Photographic evidence?

  • Description of circumstances, events and actions

  • Additional sketch

  • Type of service, vehicle or property which incurred damage

  • Address of damaged item
  • Precise nature of damage

  • Photographic evidence?

  • Description of circumstances, evens and actions

  • Additional sketch

  • Where any of these contacted?

  • Please specify

  • Was any first aid administrated?

  • What and by whom

  • What happened to the injured person following the incident/accident & any administration of first aid?

  • Please specify

  • Details of any immediate corrective action taken following the occurrence, and by whom:

  • I agree that all of the above facts are a true record of the occurrence; accident; incident or near miss

  • Name and signature

  • Date signed

  • TO BE COMPLETED BY MANAGEMENT

  • Following a review of the information provided, the company has determined the following action(s) are required

  • Date action taken

  • Conclusion statement from review

  • Actions required/ taken from review

  • Name and signature

  • Results from investigation

  • Actions required/taken from investigation

  • Name and signature

  • I confirm this accident/incident review/investigation had been concluded and all actions required, satisfied

  • Name and signature

  • Date signed

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.