First Report of Incident

• Audit Title

• Document No.

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Office use

• Report only

  Yes

  No

  N/A

• Property Damage

  Yes

  No

  N/A

• First Aid

  Yes

  No

  N/A

• Near Miss

  Yes

  No

  N/A

• Injury Requiring a Doctor

  Yes

  No

  N/A

• Eye Injury

  Yes

  No

  N/A

Classification

• Unsafe Act

  Yes

  No

  N/A

• Unsafe Condition

  Yes

  No

  N/A

• Housekeeping

  Yes

  No

  N/A

General information

• Today's Date and Time

  Date

• Employee Name

  Yes

  No

  N/A

• Department

  Yes

  No

  N/A

• Shift

  Yes

  No

  N/A

• Job Title

  Yes

  No

  N/A

• Supervisor

  Yes

  No

  N/A

• Date and Time of Incident

  Date

• Time shift began

  Yes

  No

  N/A

• Specific Location In Plant Incidnet Occured

  Yes

  No

  N/A

Incident description

• Describe the incident. Describe who, what, how, and why the incident occurred.

  Yes

  No

  N/A

Please use this section to add photos

• Add media

  Media

Corrective Action

• In your opinion what was the cause of the accident. Ask yourself why and why again.

  Yes

  No

  N/A

• What can be done to prevent this incident from occurring again?

  Yes

  No

  N/A

• Who is responsible for the corrective action items that need to be taken? Assign people and completion dates to those items.

  Yes

  No

  N/A

• Supervisor

  Sign

• Employee

  Sign

• EHS Manager

  Sign

• Production Super.

  Sign

• Production Super.

  Sign