• Document No.

  • Conducted on

  • Prepared by

  • Property name

  • Location
  • Property phone number

  • Name

  • Job title

  • Supervisor

  • Supervisor phone number

I. Background Information on Injured Person (if any)

  • Name:

  • Property:

  • Job Title:

  • Property Address:

  • Add location
  • Property Phone Number:

  • Supervisor:

  • Supervisor Phone / Extension:

II. Witnesses

  • We're there any witnesses to the incident?

  • Witness #1 Name

  • Phone number

  • Witness #2 Name

  • Phone number

III. Description of Accident / Near Miss:

  • Description of Accident / Near Miss: (Describe sequence of events, including time date and location of incident. Attach any photos, drawings, or separate page if necessary)

  • REQUIRED- Please take photos of incident area, items effecting accident, and any and all other items that may assist with the reporting of this record.

  • Add media

IV. Factors

  • Describe conditions or practices, if any, that may have led to the occurrence of this incident. Attach additional page / information if necessary)

  • Add media

  • Was this a preventable injury?

  • Was PPE required?

  • If yes, please list equipment

  • Was it worn at time of incident?

V. Corrective Actions

  • In your opinion, what are reasonable actions or steps that could be taken to eliminate or reduce the likelihood of a recurrence? (Attach additional page or information if necessary)

  • How could this injury have been a prevented? Choose the one overall appropriate area of concern that best describes the contributing cause to this preventable injury.

  • Focus

  • Training

  • Equipment Failure

VI. Emergency Services (if any)

  • Were emergency services contacted?

  • Which service provider? (Police, EMS etc?)

  • Describe medical attention provided.

  • Investigation completed By:

  • Date:

  • Select date

  • Investigators signature:

  • Community Director / Maintenance Director review and comments:

  • CD / MD Signature:

  • Employee 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.