Title Page
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Audit Title
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Prepared by
GATES FIRE DISTRICT - PERSONAL INJURY / ILLNESS REPORT
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INFO OF INJURED PERSON
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Date:
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Phone:
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Height:
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Weight(lbs):
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Years with Dept. (If less than 1, choose 0):
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INJURY LOCATION
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Organization Name:
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Address:
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City:
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State:
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Zip Code:
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County:
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Location, Address, and Description:
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B: INJURED PERSON
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SSN:
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SEX:
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CAREER/VOLUNTEER:
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ID NUMBER:
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FIRST NAME:
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MI:
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LAST NAME:
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SUFFIX
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C: CASUALTY NUMBER
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CASUALTY NUMBER:
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D: AGE OR DATE OF BIRTH
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AGE:
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-OR-
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DOB:
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E: DATE AND TIME OF INJURY
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DATE/TIME:
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F: RESPONSE
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# OF PRIOR RESPONSES DURING THE PAST 24 HRS:
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G1: USUAL ASSIGNMENT:
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G2: PHYSICAL CONDITION JUST PRIOR TO INJURY:
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G3: SEVERITY:
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G4: TAKEN TO:
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G5: ACTIVITY AT TIME OF INJURY:
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H1: PRIMARY APPARENT SYMPTOM:
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H2: PRIMARY AREA OF BODY INJURED:
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I1: CAUSE OF FIREFIGHTER INJURY:
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I2: FACTOR CONTRIBUTING TO INJURY:
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I3: OBJECT INVOLVED IN INJURY:
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J1: WHERE INJURY OCCURRED:
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J2: STORY WHERE INJURY OCCURRED
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INJURY IN RELATION TO STRUCTURE:
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STORY OF INJURY:
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J3: SPECIFIC LOCATION:
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J4: VEHICLE TYPE:
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REMARKS:
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K1: DID PROTECTIVE EQUIPMENT FAIL AND CONTRIBUTE TO THE INJURY?
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ITEM THAT FAILED:
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PROBLEM:
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MANUFACTURER:
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MODEL:
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SERIAL NUMBER:
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CAUSE & EFFECT
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Witness(es):
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INVESTIGATION
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Describe the accident in detail:
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Hospitalized or treated?
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If so, Where?
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Name and Address of Doctor:
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Did the injury result in Off or Light Duty?
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For how long?
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What Acts, Failures to Act, or Conditions -contributes most directly to this event?
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What caused these Acts or Conditions?
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Recommendations for corrective action?
Signed
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Signature of Injured Person:
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Signature of Safety Officer:
