Confidential Walk Backs

• Audit Title

• Document No.

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

This documents the answers from the injured worker's interview for accident analysis.

Information

• Description of injury from file.

  Yes

  No

  N/A

Interview

• Account of what happened

  Yes

  No

  N/A

• Has the injury healed/are there still issues arising from the accident?

  Yes

  No

  N/A

• What was the main cause of the accident?

  Yes

  No

  N/A

• What could be done to prevent a future reoccurrence?

  Yes

  No

  N/A

• Investigator's assessment:

  Yes

  No

  N/A