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Audit

Employee Details

Name

Address
Date of Birth

Gender

Phone Number

Employment Details

Job Title

Employment Status

Accident/Near Miss Details
Date & Time

Hours at Work

Accident Type

Treatment Given

Injury Details
Nature of Injury
Mark Injuries

Where did the Accident/Near Miss Happen?

How did the Accident/Near Miss Happen?

Was the person trained for the task they were doing?

Was a vehicle involved?

Type of Vehicle

Was a significant hazard involved?

What was the significant hazard?

Is the hazard on the hazard register?

How serious could the injuries have been?

Details

What happened?

Doctor visit is required?

Initial Needs assessment
Action Plan

Add steps to prevent a similar event from happening. Add action details in the paperclip icon.

Action Plan

Action Plan Summary

Completion
Worker
Health & Safety Manager
Management
Treating Doctor

General Staff Incident Report Checklist

Created by: SafetyCulture Staff | Industry: General | Downloads: 177

Use this template to report Accident, Incident, Near Misses or Equipment damage where a member of staff has been involved.

Signup for a free iAuditor account to download and edit this checklist. It will be added to your free account and you will be able to conduct inspections from your mobile device.

Download and edit this free checklist

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Audit

Employee Details

Name

Address
Date of Birth

Gender

Phone Number

Employment Details

Job Title

Employment Status

Accident/Near Miss Details
Date & Time

Hours at Work

Accident Type

Treatment Given

Injury Details
Nature of Injury
Mark Injuries

Where did the Accident/Near Miss Happen?

How did the Accident/Near Miss Happen?

Was the person trained for the task they were doing?

Was a vehicle involved?

Type of Vehicle

Was a significant hazard involved?

What was the significant hazard?

Is the hazard on the hazard register?

How serious could the injuries have been?

Details

What happened?

Doctor visit is required?

Initial Needs assessment
Action Plan

Add steps to prevent a similar event from happening. Add action details in the paperclip icon.

Action Plan

Action Plan Summary

Completion
Worker
Health & Safety Manager
Management
Treating Doctor