GPS Incident Report

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Site Information

• Name of Employee:

• Supervisor's name:

• Employer:

• Project name:

• Project number:

Occurrence Details

• Description of incident

• Location of incident

• Specify:

  Date

• Approximately:

  Date

• Weather Condition:

• Fine

• Warm

• Hot

• Cool

• Cloudy

• Windy

• Wet

• Dry

Incident Classification

• First Aid

• Near Miss

• Recordable, No Restricted Days, No Days Away

• Recordable, Restricted Activity

• Recordable, Days Away

• Fatality

• Non-Chargeable Vehicle

• Chargeable Vehicle

• Minor Incident

• Serious Incident

• DOT Vehicle

• DOT Reportable

• General Liability, Property Damage, Property Loss

• Other

• Specify:

Incident Details

• Working at Heights

• Working at the Ground

• Authority Notified:

• Supervisor

• Foreman

• Safety

• Where on Body

• Head/Face

• Eye

• Neck

• Ear

• Shoulder

• Body/Skin

• Back/Spine

• Arm/Elbow

• Hand/Wrist

• Leg/Knee

• Foot/Ankle

• Other

• Specify:

• Nature of Injury

• Fracture

• Sprain/Strain

• Dislocation

• Laceration (wound)

• Internal

• Bruise/Crushing

• Foreign Body

• Hearing impairment

• Burn

• Superficial (scratch)

• Asphyxia

• Heart Attack

• Illness

• Multiple

• Other

• Specify:

• Agency (How)

• Power Tools

• Non Powered Hand Tools

• Chemicals

• Other Materials / Substances

• Outdoor Environment

• Indoor Environment

• Unspecified Agencies

• Other

• Specify:

• Mechanism (How)

• Fall From Heights

• Fall From Same Level

• Strike Against

• Struck By

• Repetitive Movement

• Other Muscular Stress

• Contact with Electricity

• Exposure to:

• Select Heat Cold Substance Pressure Noise Vibration

  • Heat
  • Cold
  • Substance
  • Pressure
  • Noise
  • Vibration

• Excavation

• Caught Between

• Other

• Specify:

• HSE Manager

  Sign