Information

  • Document No.

  • Audit Title

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Personnel

Accident/Incident Details

  • Site that employee was working at;

  • Date and time of injury;

  • Employee Name

  • Job Title:

  • Location of accident (please be specific)

  • Nature of Incident or Injury

  • Was a JSA, Take 5 or Risk Assessment completed before work began:

  • Describe who, what, when,where, why and how injury occurred:

  • Contributing causes of the Incident: (Inadequate training, Inadequate supervision. Employee not following proper safety procedures and instructions)

  • Possible Cause or Causes of the incident: (Inadequate PPE, Not Paying attention to surroundings, failure to utilise safety equipment)

  • 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.)

  • WHS Informed?

  • ESO Informed?

  • Date and Time when the employer was notified:

  • Severity:

  • Witnesses

  • Witnesses

  • Witnesses

Injury Details if Applicable

  • Where was the Medical treatment first provided?

  • What type of provider performed treatment?

  • If you choose other please specify.

  • Provider Doctor Details

  • Part of Body injured:

  • Will the employee have any restrictions:

  • If so, what are they?

  • Do we have Light duty for him based on restrictions?

  • Anyone else injured:

Corrective Actions

Action: Short Term

  • What was the immediate action taken to correct the issue (how was this done):

  • Who was the responsible party for correcting the issue:

Action: Long Term

  • What is the long term action needed to correct the issue:

  • Who was the responsible party for correcting the issue:

Additional Information

  • Lessons Learned:

  • Drawings applicable to Incident

  • Please provide all attachments that apply: Pictures, Drawings, Training Records, Statement of Employee, Statement of Witness/es, Other.

Person Completing Form (please sign below)

  • Add signature

Electrical Worker in Charge (please sign below)

  • Add signature

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.