Information
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Incident No.
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Audit Title
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Client / Job Number
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Conducted on
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Prepared by
GENERAL INFORMATION ABOUT THE INVESTIGATION
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Date investigation opened
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Were the Police notified or on-site?
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Name / Phone Number / Agency
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Explain: (be as specific as possible).
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Investigated by:
(includes other employers)
investigator
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Name / Phone Number / Company
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Date investigation closed
GENERAL INFORMATION ABOUT THE PROJECT
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Project Title
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Project Manager / Phone Number
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Project General Foreman / Phone Number
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Project Site Foreman / Phone Number
GENERAL INFORMATION ABOUT THE INCIDENT
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Date and time of incident (if known)
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Address / Location
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Road Type
- Freeway/Express Way (60-70mph)
- Rural Highway (50-60mph)
- Rural Road (40-50 mph)
- Rural Road/Urban Arterial (35-40 mph)
- Rural Road/Urban Street/Residential-Business (25-35 mph)
- Urban Street/Residential Neighborhood (<25 mph)
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Traffic Volume
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Incident Site
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Briefly describe the incident.
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Photographs of Incident Site
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Did the incident result in any of the following? (check all that apply)
- Fatality
- Serious injury
- Non-Serious injury
- Property damage
- Near miss
VICTIM AND WITNESS STATEMENTS
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Statements
Victim or Witness
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This person is a
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Name / Phone Number / Company
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Their Statement:
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Signature
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Was this person physically injured?
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Describe the injuries. Be as specific as possible.
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Did this person receive medical treatment beyond basic first aid?
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Hospital/Clinic/Physician
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Does this person's account of the incident support the victim's account?
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Explain: (be as specific as possible).
EXTENT OF DAMAGE
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Was there any damage?
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What was damaged? (be as specific as possible)
Item
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Description of item damaged. (Property or vehicle make/model/color/plate number)
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Photographs of damage.
INCIDENT ANALYSIS
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Was a police report, warning or citation issued?
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Explain: (be as specific as possible).
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Incident Cause
Cause
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Were conditions unsafe at time of incident? (physical, environmental, mechanical)
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Explain: (be as specific as possible).
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Was an unsafe/at-risk behavior or action a factor in the incident?
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Explain: (be as specific as possible).
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Is there a specific safety rule or regulation that was violated?
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Describe: (be as specific as possible).
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Has disciplinary action been taken? Describe.
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Immediate action required?
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When should this action be completed
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Who is responsible to oversee this action?
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Long term action required?
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When should this action be completed
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Who is responsible to oversee this action?
FOLLOW-UP INVESTIGATION
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Is a follow-up investigation required?
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Who is responsible to oversee this action?
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Follow-up investigation completed on
SUBROGATION
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Are there opportunities for subrogation in this case?
Subrogation opportunity
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Name/Company
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Reason/justification
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Has all physical evidence been secured, photographed, or otherwise preserved?
