Information

  • Document No.

  • Audit Title (name and or incident title).

  • Location Incident Occurred.

  • Date and Time of Incident.

  • Responded By.

  • Prepared By

  • Location

Incident Detail

  • Incident Description:

Injury / Illness Detail

  • Does the Incident Involve an Illness or Injury?

  • Tap to enter information Add Each Injured Employee (Click the add button to the right).
  • What is the Employees Name (Last, First, M.I.)?

  • Date of Birth:

  • Date of Hire

  • Length of service in current position:

  • Job Title

  • Short service employee (SSE)?

  • Employment status:

  • Did the incident result in a fatality?

  • Was the incident work related?

  • Would you describe the condition as an injury or illness?

  • Has/will the employee be unable to attend work for more than 24-hours as a result of this incident or told by a doctor not to return to work?

  • Has/will the employee need to have his normal duties altered as a result of this incident?

  • Has the employee received medical treatment beyond first aid?

  • Body parts injured:

  • Nature of accident:

  • Add pictures of injury if appropriate:

  • Was employee doing his regular job?

  • Date employer learned of injury:

  • Able to work at least (1) full day after date of injury?

  • Date lost time began:

  • Date restricted time began:

  • Return to work date (or expected):

  • Restricted time end (or expected):

Auto Incident Detail

  • Would you like to enter an Auto Incident?

  • Tap to enter information Add all drivers (click the add button to the right for each driver):
  • Is this a Harris Companies employee or other driver?

  • Name (Last, First M.):

  • Date of birth:

  • Driver contact #:

  • Address:

  • Operator's license #:

  • License class:

  • License expiration:

  • Length of service in current position (Harris Employee):

  • Position:

  • Employment status:

  • Add all vehicles involved (click the add button to the right for each vehicle):
  • Who does the vehicle belong to?

  • Vehicle type:

  • Year/make/model of vehicle:

  • Vehicle license plate #:

  • Vehicle identification # (VIN):

  • Names of all passengers involved:

  • Was driver wearing a seatbelt?

  • Were passengers wearing seatbelts?

  • Where may the vehicle be seen?

  • Describe damage to vehicle:

  • If able take pictures of all vehicle damage. (click the button to the right):

  • Speed before incident:

  • Speed at impact:

  • Damage to property of others?

  • Describe damage to property of others:

  • If able take pictures of all property damage (click the button to the right):

  • Insurance company (other driver):

  • Insurance agent name (other driver):

  • Insurance telephone # (other driver):

  • Insurance policy # (other driver):

  • Add all equipment involved (click the add button to the right for equipment involved):
  • Equipment description:

  • Part #:

  • Part description:

  • Model #:

  • Serial #:

  • If able take pictures of all equipment damage (click the button to the right):

  • Tap to enter information

General auto incident questions:

  • Was fault admitted or discussed at the scene?

  • Alcohol/drugs involved?

  • Were police summoned to the scene?

  • Who was charged or ticketed by police?

  • Was our vehicle parked off road at the time of the incident?

  • Was our vehicle parked legally on a public roadway?

  • Was our vehicle damaged as part of a theft, road chips, environmental damage, or vandalism?

  • Was our vehicle tied directly to a work specific function?

  • Could mileage be reimbursed for this journey?

  • Was the employee traveling between facilities and not to and from work?

  • Was our driver improperly licensed or had no license for the vehicle?

  • Did our driver strike a stationary object?

  • Did our driver exceed the posted speed limit or was excessive speed a factor?

  • Was our driver fatigued?

  • Was our driver distracted due to electronic devices, etc?

  • Tap to enter information
  • What was the source of distraction?

  • Was our driver in violation of any local laws?

  • Did our driver receive a citation

  • Was a poorly secured load a factor in this incident?

  • Did our driver or any occupants fail to wear seatbelts?

  • Did our driver fail to complete all required driver training?

  • Did our driver fail to meet all expectations of the Global Journey Management policy at the time of the incident (if required)?

  • Were preventable vehicle defects a factor?

  • Add pictures of vehicle defects if possible (click the button to the right):

  • Were any vehicle towed from the scene?

  • Did any individual leave the incident scene in an ambulance?

  • Were there any fatalities?

  • Did any Harris employee sustain a recordable injury?

  • Direction of travel:

  • Roadway type:

  • Road conditions:

  • Weather conditions:

  • Add pictures of road type/weather/traffic flow (click the button to the right):

  • Condition of our driver:

  • Incident type:

  • Manner of collision

  • Traveling in convoy?

  • Location of incident:

  • Street or route:

  • Nearest intersection:

  • City/county/state:

  • If you need to add more than one driver or vehicle scroll up and click add for each additional item. Once you are done with this section slide left to access the next step.

Investigation completion.

Forms

  • For motor vehicle incidents complete:

    Auto Loss Notice Form
    Members statement
    Supervisor Incident report

    For Personal injury complete:

    Employee's 1st report (DWC-1)
    Employer's 1st report (5020)
    Supervisors Incident report
    Members statement
    Letter to medical provider
    Restricted duty form

    Others:

    Property Loss Damage report
    General Liability form

    Employee injuries that require a doctors visit and all motor vehicle incidents require a drug and alcohol screening with a quick test result.

  • Have all sections been complete?

  • Tap to enter information
  • Once all sections are complete sign below and email your incident investigation to your HSSE department.

  • Type your name below and click the sign button to the right.

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.