• Document No.

  • Audit Title

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Personnel

  • Location

  • Job #:

  • Date of occurrence

  • Date reported

  • GWR Employee?

  • Contractor?

Type of Incident. Select all that apply.

  • Near Miss?

  • First aid?

  • Medical Aid?

  • Restricted Work?

  • Lost Time Injury?

  • Occupational Illness?

  • Fire or Explosion?

  • Equipment Failure?

  • Property Damage?

  • Material or Business Loss

  • Motor Vehicle Accident

  • Threats?

  • Other


  • What type of injury?

  • What body part was injured?

  • Was follow-up treatment required?

Person Involved

  • Employee name

  • Date of Birth

  • Address

  • SIN#

  • Health Care#


  • Clearly describe how the incident occurred.


  • Include the names and phone numbers of any witnesses to the incident. Attach witness statements.


  • Immediate causes, what acts failure to act, and conditions contributed directly to this accident?

  • Basic causes, what are the contributing factors? (Job factors, personal factors)


  • What action or recommendations are made to prevent recurrence? When? And action by?

Frequency Potential

  • Frequent

  • Probable

  • Occasional

  • Remote

  • Improbable


  • Catastrophic

  • Critical

  • Moderate

  • Minor


  • Estimated:

  • Actual:


  • Extra comments

  • Investigated by:

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.