Accident/Incident/Near Miss Investigation Report

• Audit Title

• Document No.

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

If a blank does not pertain to your incident,accident, injury or illness, type "N/A" in the blank.

• Name:

• Address/Phone#:

• Date of Birth:

• Job Title:

• Date Hired:

• Supervisor:

• Incident Date/Time:

• Location:

• Task Performed:

• # of Hours Worked

• # of Hours Awake

• # of Hours Slept

• Witness:

• Immediate Supervisor:

• Safety Equipment Used

• Medical Treatment Requested

  Yes

  No

• Severity of Incident

  Injury

  Light Trauma

  Heavy Trauma

• Was First Aid Given?

  Yes

  No

• If Yes....

  Date

• First Aider Qualification:

• First Aider Address & Phone#:

• Detailed Description of Incident:

• What Caused Incident?

• Employee Recommendation for Incident Prevention:

• Signature of Employee/Date:

  Sign

• Signature of Witness/Date:

  Sign

Supervisor's investigation Report

• Supervisor Completing Report's Name:

• Injury Details

  Date

• Location:

• Task Performed:

• Witness:

• Injured Party:

• Property Damaged:

• Injury:

  Light Trauma

  Heavy Trauma

• Body Part Affected:

  Select Head Arms Legs Fingers Torso Toes Feet Eyes Back Ears Hands Other

  • Head
  • Arms
  • Legs
  • Fingers
  • Torso
  • Toes
  • Feet
  • Eyes
  • Back
  • Ears
  • Hands
  • Other

• Outcome:

  Select Information Only First Aid Medical Treatment Light Duty Incident Lost Time Incident Fatality

  • Information Only
  • First Aid
  • Medical Treatment
  • Light Duty Incident
  • Lost Time Incident
  • Fatality

• # Of Lost Days

• # Of Restricted Days

• HSE Severity:

  Minor

  Serious

  Catastrophic