Information
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Audit Title
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Document No.
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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
Part A. Accident/Incident portion.
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Select date
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Name Branch that employee was working for:
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Employee Name (First, MI, Last): (Look at ID)
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SSN #
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Date of Birth;
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Did employee die?
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Gender
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Date of Injury/Icident:
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Time of Injury/Incident:
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Return to work date/or expected date:
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Will the employee have any restrictions:
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If so, what are they?
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Do we have Light duty for him based on restrictions?
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Date and Time wen the employer was notified:
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Employee's Home Address and Phone Number
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Does Employee Speak English:
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What Language:
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Marital Status:
- Single
- Married
- Widowed
- Divorced
- Separated
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Number of Dependents
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
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Number of Dependents under 18
- 1
- 2
- 3
- 4
- 5
- 6
- 7
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Spouse's Name:
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Hire Date:
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Ave. Hrs Worked per week:
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Ave. Weekly Wage:
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Job Title:
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Did he receive full pay for date of injury:
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Superintendent Name and Phone Number:
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Proyect Name, Number and Address where Accident occur.
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Witnesses
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Witnesses
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If the answer was yes, please provide Full Name, Phone Number and Employer:
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If the answer was yes, please provide Full Name, Phone Number and Employer:
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Where was the Medical treatment first provided?
- Minor Onsite
- Physician/Clinic
- ER Treated/Released
- Hospitalized > 24 hrs
- Hospitalized < 24hrs
- No Medical Treatment
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What type of provider performed treatment?
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Providers Name:
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If you choose other please specify.
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Provider Phone Number, Address and Name of the Doctor.
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Anyone else injured:
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Name of the Superintendent and/or other office personnel who went whit the injured to the clinic/hospital. This is mandatory and must stay there the entire time.
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Nature of Injured.
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Part of Body injured:
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Was the employee doing his regular job:
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Describe who, what, when,where, why and how injury occurred:
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Location of accident (please be specific)
Person Completing Part A ( please sing below)
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Add signature
Part B. Investigation portion.
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Employee Name (First, MI, Last)
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Contract Relationship (Company Name)
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Date of Hire:
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Was the person injured a new hire:
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Which one applies to the accident / incident:
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Total Yrs. of experience.
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Incident Type:
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Please explain further:
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Severuty:
- First Aid
- Recordable
- Lost Time
- Restricted Duty
- Fatality
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Was a Pre-Job Safety Briefing (JHA) Held before work began:
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Was employee present:
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Describe the work Activity in Progress at the time of the incident. (What was the Employee doing, How did the Incident occur)
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Describe the Incident. (Where was the employee, what was the employee doing, How did the Incident occur)
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Cause or Causes of the incident: (Inadequate PPE, Not Paying attention to surroundings, failure to utilize safety equipment)
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Contributing causes of the Incident: (Inadequate training, Inadequate supervision. Employee not following proper safety procedures and instructions)
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What is the employee's current status if injured: Describe. ( Returned to work the next day, off of work do to injury, off of work do to restrictions, In hospital, etc.)
Corrective Actions
Action:
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What was the immediate action taken to correct the issue (how was this done):
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Who was the responsible party for correcting the issue:
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Select date
Action:
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What is the long term action needed to correct the issue:
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Who was the responsible party for correcting the issue:
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Select date
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Lessons Learned:
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Please provide all attachments that apply: Pictures, Drawings, Training Records, Statement of Employee, Statement of Witness/es, Other.
Statement of Employee involved in the accident/incident
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Please provide date of incident,time, phone number and description of the incident according to the employee in his words:
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Add signature
Statement of the Witness (1)
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Name of witness, Company that he / she works for, Phone Number, Date and Time of the accident/incident according to the witness.
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Statement in his words:
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Add signature
Statement of the Witness (2)
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Name of witness, Company that he / she works for, Phone Number, Date and Time of the accident/incident according to the witness.
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Statement in his words:
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Add signature
