Information
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Document No.
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Audit Title
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Client / Site
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Conducted on
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Prepared by
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Location
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Personnel
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Location
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Job location:
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Date of occurrence
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Date reported
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KOT Employee?
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Contractor?
Type of Incident. Select all that apply.
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Near Miss?
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First aid?
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First Aid By Professional ?
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Restricted Work?
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Lost Time Injury?
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Non Occupational Illness?
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Recordable Injury?
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Equipment Failure?
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Property Damage?
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Material or Business Loss
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Motor Vehicle Accident
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For Report Only
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Other
Injury
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What type of injury?
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What body part was injured?
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Was follow-up treatment required?
Person Involved
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Employee name
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Date of Birth
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Address
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SS#
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Phone#
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Hire Date?
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Experience with KOT?
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Experience With Position
Witnesses
Description
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Clearly describe how the incident occurred.
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Include the names and phone numbers of any witnesses to the incident. Attach witness statements.
Analysis
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Immediate causes, what acts failure to act, and conditions contributed directly to this accident?
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Basic causes, what are the contributing factors? (Job factors, personal factors)
Prevention
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What action or recommendations are made to prevent recurrence? When? And action by?
Frequency Potential
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Frequent
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Probable
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Occasional
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Remote
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Improbable
Severity
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Catastrophic
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Critical
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Moderate
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Minor
Costs
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Estimated:
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Actual:
Conclusion
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Extra comments
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Investigated by:
