Information
-
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
Injury
-
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#
Description
-
Clearly describe how the incident occurred.
Witnesses
-
Include the names and phone numbers of any witnesses to the incident. Attach witness statements.
Analysis
-
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)
Prevention
-
What action or recommendations are made to prevent recurrence? When? And action by?
Frequency Potential
-
Frequent
-
Probable
-
Occasional
-
Remote
-
Improbable
Severity
-
Catastrophic
-
Critical
-
Moderate
-
Minor
Costs
-
Estimated:
-
Actual:
Conclusion
-
Extra comments
-
Investigated by:
