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Audit

1. EVENT DETAILS
Please click "Add Investigator" button.

Investigator Name

Date and Time of the Event
Date First Reported
Date of this Report
EVENT TYPE AND DEFINITION

Hazard Report (no incident reported, complete report Follow-up)

Near Miss (any event/observation that could have resulted in injury or property damage)

Minor Harm Accident (Onsite First Aid treatment / potential future harm)

Harm Accident (Off site medical treatment and rehabilitation/ rest for not serious or permanent injury)

Serious Harm Injury (as defined by the act – refer to your policy before ticking)

Damage to Machinery / Property Plant / Equipment / Property Damaged Details

Has Work safe been notified?

What is a notifiable incident?

2. INVOLVED PERSONS
Please click "Add Name" button.

Name of Injured / Near Miss Person

Employer

Please Specify

Name of Witness / Witnesses and Contact Phone Number(s)

Brief Summary of Event and Findings

Describe the Event

How was this allowed to happen within our company? (what processes were broken, safeguards non-existent, etc that allowed this to happen on our watch? List all that apply)

Training – Competency / Formal

Risk Assessments and Documentation

Equipment Involved

Process Failure

risky3.png

How Serious could this have been?

The likelihood of such an event reoccurring

If the event did reoccur, the likely consequence would be

The risk score is therefore
3. TREATMENT AND FOLLOW-UP

What was the resulting injury?

What treatment was given to immediately address the issue?
Attach doctors/hospital report

What are the items used?

4. RESULTING ACTIONS

What can we do better to eliminate/minimize such an event reoccurring?

Tick items already actioned

Completed by Name and Signature
Date and Time of Completion

Include training and consider feedback from the investigation process in planning actions

Completed by Name and Signature
Date and Time of Completion

Refer to your policy to check if incident needs to be reported to Work Safe

Completed by Name and Signature
Date and Time of Completion
5. SUPPORTING MEDIA, DOCUMENTATION AND REPORTS
Please click "Add Item" button.

Please Specify the item

Please put your comments here

Please upload a photo of the item
COMPLETION AND SIGN-OFF

Investigators Review and Sign-Off

Please click "Add Investigator" button.
Investigator Name and Signature

Management Review and Sign Off

Manager Name and Signature

CCL INCIDENT INVESTIGATION REPORT CHECKLIST

Created by: SafetyCulture Staff | Industry: General | Downloads: 11

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Audit

1. EVENT DETAILS
Please click "Add Investigator" button.

Investigator Name

Date and Time of the Event
Date First Reported
Date of this Report
EVENT TYPE AND DEFINITION

Hazard Report (no incident reported, complete report Follow-up)

Near Miss (any event/observation that could have resulted in injury or property damage)

Minor Harm Accident (Onsite First Aid treatment / potential future harm)

Harm Accident (Off site medical treatment and rehabilitation/ rest for not serious or permanent injury)

Serious Harm Injury (as defined by the act – refer to your policy before ticking)

Damage to Machinery / Property Plant / Equipment / Property Damaged Details

Has Work safe been notified?

What is a notifiable incident?

2. INVOLVED PERSONS
Please click "Add Name" button.

Name of Injured / Near Miss Person

Employer

Please Specify

Name of Witness / Witnesses and Contact Phone Number(s)

Brief Summary of Event and Findings

Describe the Event

How was this allowed to happen within our company? (what processes were broken, safeguards non-existent, etc that allowed this to happen on our watch? List all that apply)

Training – Competency / Formal

Risk Assessments and Documentation

Equipment Involved

Process Failure

risky3.png

How Serious could this have been?

The likelihood of such an event reoccurring

If the event did reoccur, the likely consequence would be

The risk score is therefore
3. TREATMENT AND FOLLOW-UP

What was the resulting injury?

What treatment was given to immediately address the issue?
Attach doctors/hospital report

What are the items used?

4. RESULTING ACTIONS

What can we do better to eliminate/minimize such an event reoccurring?

Tick items already actioned

Completed by Name and Signature
Date and Time of Completion

Include training and consider feedback from the investigation process in planning actions

Completed by Name and Signature
Date and Time of Completion

Refer to your policy to check if incident needs to be reported to Work Safe

Completed by Name and Signature
Date and Time of Completion
5. SUPPORTING MEDIA, DOCUMENTATION AND REPORTS
Please click "Add Item" button.

Please Specify the item

Please put your comments here

Please upload a photo of the item
COMPLETION AND SIGN-OFF

Investigators Review and Sign-Off

Please click "Add Investigator" button.
Investigator Name and Signature

Management Review and Sign Off

Manager Name and Signature