BreatheSafe Incident Report

• Audit Title

• Document No.

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

SECTION I

• Date and time of incident

  Date

• Date and time incident was reported.

  Date

• To whom was the incident reported?

• Location of incident. (Specify site location)

• Supervisor's Name

• Supervisor's Phone Number

• Was there any witness(es)? If yes, provide name(s).

  Yes

  No

  N/A
PERSON(S) INVOLOVED

• Name (Person 1):

• Phone:

• Sex:

  Male

  Female

• Age;

• Job Title:

• Time on job: (Yrs & Mos)

• Job Status:

  Full-time

  Part-time

  Temporary

  Seasonal

• Classification:

  Select First-Aid only Medical Near miss Lost time OH&S Reportable None

  • First-Aid only
  • Medical
  • Near miss
  • Lost time
  • OH&S Reportable
  • None

• Employee Disposition Status:

  Returned to Work

  Modified Duties

  Sent Home

  To Doctor

  To Hospital

• Medication prescribed? If yes list medications.

  Yes

  No

  N/A
NATURE OF INJURY

• Describe injury.

• Detail any first-aid or medical treatment administered. (Provide names)

• Property Damage:

  N/a

  Vehicle

  Equipment

  Private Property

• Photo of damage.

  Media

• Estimated cost of damage:

• Vehicle ID:

• Make/Model:

• Age:

• Equipment ID:

• Model:

• Age:

• Detailed description of incident. (Include environmental conditions at time of incident)

Photos of area or equipment involved

• Immediate (Direct Causes):

• Direct cause photo:

  Media

• Direct cause photo:

  Media

• Contributing (underlying) Factors:

• Contributing factors photo:

  Media

• Corrective Action (Include detail description of action and person(s) responsible for actions)

• What was the potential for severity?

  Minor

  Serious

  Major

• What could have potentially happened?

• What is the probability of reoccurrance?

  Remote

  Improbable

  Probable

• Select date

  Date

• Signature

  Sign