Information
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Audit Title
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Document No.
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Client / Site
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Conducted on
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Prepared by
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Location
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Personnel
SECTION I
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Date and time of incident
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Date and time incident was reported.
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To whom was the incident reported?
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Location of incident. (Specify site location)
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Supervisor's Name
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Supervisor's Phone Number
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Was there any witness(es)? If yes, provide name(s).
PERSON(S) INVOLOVED
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Employee or Guest
- Employee
- Guest
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Name (Person 1):
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Phone:
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Sex:
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Age;
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Job Title:
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Time on job: (Yrs & Mos)
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Job Status:
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Classification:
- First-Aid only
- Medical
- Near miss
- Lost time
- OH&S Reportable
- None
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Employee Disposition Status:
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Medication prescribed? If yes list medications.
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Employee or Guest Statement of Incident
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Witness Statement
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Witness Statement
NATURE OF INJURY
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Describe injury.
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Detail any first-aid or medical treatment administered. (Provide names)
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Property Damage:
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Photo of damage.
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Property Damage:
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Photo of damage.
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Estimated cost of damage:
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Environmental photo:
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Environmental photo:
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Immediate (Direct Causes):
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Direct cause photo:
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Direct cause photo:
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Contributing (underlying) Factors:
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Contributing factors photo:
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Corrective Action (Include detail description of action and person(s) responsible for actions)
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What was the potential for severity?
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What could have potentially happened?
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What is the probability of reoccurrance?
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Select date
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Signature
