Audit
Location
Job #:
GWR Employee?
Contractor?
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?
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?
Frequent
Probable
Occasional
Remote
Improbable
Catastrophic
Critical
Moderate
Minor
Estimated:
Actual:
Extra comments
