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
Part A. Accident/Incident portion.
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Investigation date:
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Name Branch that employee was working for:
- W.C. Spratt, Inc.
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Employee name:
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Employee #:
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Date of birth:
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Did the employee die?
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Gender:
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Time and date of injury:
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Return to work date/or expected date:
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Average hours worked per week:
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Will the employee have any restrictions:
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If so, what are they?
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Are light duty restrictions available for the injured?
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Date and Time when the employer was notified:
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Does employee speak english:
- Yes
- No
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What language:
- English
- Spanish
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Hire date:
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Did he receive full pay for date of injury:
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Job title:
- Dozer Operator
- Driver
- EX-Operator
- Laborer
- Operator
- Pipe Layer
- Superintendant
- Project Manager
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Supervisor name and phone number:
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Project Name, number and address where accident occurred:
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Witnesses:
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If the answer was yes, please provide full name, phone number and employer:
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Where was the medical treatment first provided?
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If you choose other please specify.
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Providers name:
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Provider Phone Number, Address and Name of the Doctor.
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Anyone else injured:
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Nature of Injured.
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Part of body injured:
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Was the employee doing his regular job:
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Describe who, what, when,where, why and how injury occurred:
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Location of accident (please be specific)
Person Completing Part A ( please sign below)
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Add signature
Part B. Investigation portion.
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Employee name (first, middle initial, and last):
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Contract relationship (company name):
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Date of hire:
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Was the person injured a new hire:
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Which one applies to the accident / incident:
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Total years of experience:
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Incident type:
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Please explain further:
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Severity:
- First Aid
- Recordable
- Lost Time
- Restricted Duty
- Fatality
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Was employee present:
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Was a pre-job safety briefing (tailgate meeting) held before work began?
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What topic was reviewed?
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Was a job hazard analysis completed for the work activity in question?
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Was the hazard identified in the job hazard analysis?
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Describe the work activity in progress at the time of the incident. (What was the employee doing, How did the Incident occur)?
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Describe the incident. (Where was the employee, what was the employee doing, How did the Incident occur)?
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Causes of the incident: (Inadequate PPE, Not paying attention to surroundings, behavior based):
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Contributing causes of the Incident: (Inadequate training, Inadequate supervision. Employee not following proper safety procedures and instructions)
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What is the employee's current status if injured: Describe. ( Returned to work the next day, off of work do to injury, off of work do to restrictions, In hospital, etc.)
Corrective Actions
Action:
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What was the immediate action taken to correct the issue (how was this done):
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Who was the responsible party for correcting the issue:
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What date must the corrections be implemented and observed?
Action:
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What is the long term action needed to correct the issue:
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Who was the responsible party for correcting the issue:
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What date must the corrections be implemented and observed?
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Lessons Learned:
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Please provide all attachments that apply: pictures, drawings, training records, statement of employee, statement of witness, or other:
Statement of Employee involved in the accident/incident
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Please provide date of incident,time, phone number and description of the incident according to the employee in their own words:
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Add signature
Statement of the Witness (1)
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Name of witness, company that he / she works for, phone number, date and time of the accident/incident according to the witness.
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Statement in their own words:
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Add signature
Statement of the Witness (2)
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Name of witness, company that he / she works for, phone number, date and time of the accident/incident according to the witness.
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Statement in their own words:
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Add signature
