Title Page

  • Site conducted

  • Name of Employee:

  • Designation of Employee:

  • Clock Number:

  • Area of Department/Team:

  • Department/Team

  • Location of Incident

  • Date and Time of Incident:

  • Date and Time Incident Reported:

  • Conducted on:

  • Prepared by:

  • Supervisor:

  • Safety Rep:

Loss

  • What type of incident was this?

  • Case Number:

  • Driver Name:

  • Vehicle Registration:

  • Is there a 3rd party involved

  • Has Group Services been notified?

  • Claim Number:

  • If accident has taken place on a public road, has SAPS been notified?

  • AR Number:

  • Is there damage to the vehicle?

  • Description of Damage:

  • Cost of Damage: R

  • Asset Number:

  • Description of Damage:

  • Cost of Damage: R

  • Is this an insurance claim?

  • Has Group Services been notified?

  • Type of work being performed?

  • Specify:

  • Short Description Of Incident (What happened and How?)

  • Has the Manager investigated and found negligence on the part of any employee involved?

  • Reason:

  • Is the employee liable for the repair cost?

Injury Details

  • Is this a work related incident?

  • Expected Period of Disablement:

  • Nature of Injury:

  • Specify:

  • Accident Type:

  • Specify:

  • Part of Body:

  • Specify:

  • Root Cause Analysis (5 why's)
  • Why: ... (specify your question)

  • Answer:

  • Recommended steps to prevent reoccurance:
  • undefined

  • Action taken by employer to prevent the recurrence of a similar incident:
  • undefined

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  • Employee Signature:

  • Safety Rep Signature:

  • Supervisor Signature:

  • Investigator Signature:

  • Group OHS Officer Signature:

  • Safety Committee Chairman:

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.