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:

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