Bobcat Incident Report

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

• Document #

• Site:

• Client:

• Conducted on:

  Date

• Prepared by:

• Location:
  Address

• Take as many photos of the scene as possable

  Media

• What type of incident occurred?

  Select Yes No N/A

  • Yes
  • No
  • N/A

• Personnel Hire date:

  Date

• Employment Status of Injured Person

  Select Full Timr Part Time Contractor Visitor

  • Full Timr
  • Part Time
  • Contractor
  • Visitor

• Date and Time of incident.

  Date

• Name of Injured Personnel

• Personnel phone:

• Personnel Home Adress

• What object/substance directly injured the employee

• Describe the injury and parts of the body affected:

• Injured Personnel; State in your own words a description of the day's events leading up to the incident and the actual incident.

• Injured Personnel: Is there anything that could have prevented or lessened the severity of this injury?

• Was on-site first aid treatment given?

  Yes

  No

  N/A

• Is the employee requesting or in need of medical attention?

  Yes

  No

  N/A

• Injured Personel

  Sign

• Investigator: Give an accurate description of the nature and extent of the injury and state your objective findings:

• Witness name and statement:

• Were safeguards or safety equipment used?

  Yes

  No

  N/A

Root Cause Analysis:

• What is the root cause of the incident.

Immediate Corrective Actions:

• Enter corrective actions taken to prevent immediate reoccurrence. Enter suggestions for future corrective actions.

• Management signature:

  Sign

• Investigator signature:

  Sign