Delta Company Ltd.

• Audit Title

• Document No.

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Employee General Information:

• Event Type:

• Loss Type:

• Operating Area:

• Location:
  Address

• Department

• Date:

  Date

Evaluate What Could Have Happened, Not What Have Happened

• Matrix

  

• Description of the Event:

Reported by:

• Name:

• Position:

• Telephone:

• The person responsible for the investigation and submission of report about the incident:

• Follow-up meeting:

  Date

• Date of the initial Meeting:

  Date

• The final report due date:

  Date

• Note: In the case of presence of picture, please pit in a file and attach with initial report send this form within 24 hours of the accident or near-miss incident.