Title Page
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Department
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Date
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Prepared by
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Location
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INSTRUCTIONS:
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1. Select the type of audit and answer the applicable questions below.
2. Add photos and notes by clicking on the paperclip icon.
3. To add a Corrective Measure click on the paperclip icon then "Add Action", provide a description, assign to a member, set priority and due date.
4. Complete audit by providing digital signature.
5. Share your report by exporting as PDF, Word, Excel or Web Link. -
Please select the type of audit.
- Near Miss Report
- Incident/Property Damage Report
- Employee’s Report of Injury
- Supervisor’s Accident Investigation
NEAR MISS REPORT
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A near miss is a potential hazard or incident that has not resulted in any personal injury. Unsafe working conditions, unsafe employee work habits, improper use of equipment or use of malfunctioning equipment have the potential to cause work related injuries. It is everyone’s responsibility to report and /or correct these potential accidents/incidents immediately. Please complete this form as a means to report these near-miss situations.
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Date and Time
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Please select all appropriate conditions
- Unsafe Act
- Unsafe Condition
- Unsafe Equipment
- Unsafe Use of Equipment
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Description of incident or potential hazard
NEAR MISS INVESTIGATION
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Description of the near-miss condition
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Causes (primary and contributing)
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Corrective action taken (Remove the hazard, replace, repair, or retrain in the proper procedures for the task)
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Not completed for the following reason
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NOTE: Submit completed form to the Safety Department so it may be discussed at toolbox meetings throughout the organization.
COMPLETION
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Employee Signature
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Signed
INCIDENT/PROPERTY DAMAGE REPORT
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Reported By
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Date and Time of Incident
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Location of Incident
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Was Police Department Notified?
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Fire Department
INCIDENT REPORT
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Please select and provide a brief description of the type of damage
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Brief description
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Please specify the type of damage and a brief description.
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Briefly describe what happened
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Estimated Loss
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Were photos taken?
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Were photos labeled?
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Witnesses: (Click "Add Witness")
Witness
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Name
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Date
COMPLETION
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Completed by
EMPLOYEE'S REPORT OF INJURY
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Instructions:
Employees shall use this form to report all work related injuries, illnesses, or “near miss” events (which could have caused an injury or illness) – no matter how minor. This helps us to identify and correct hazards before they cause serious injuries. This form shall be completed by employees as soon as possible and given to a supervisor for further action. -
I am reporting a work related
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Your Name
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Job Title
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Supervisor
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Have you told your supervisor about this injury/near miss?
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Date and time of injury/near miss
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Date and time reported to Supervisor
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Are there witnesses?
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Names of Witnesses: (Click "Add Witness")
Witness
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Name
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Where, exactly, did it happen?
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What were you doing at the time?
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Describe step by step what led up to the injury/near miss.
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What could have been done to prevent this injury/near miss?
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Did you see a doctor about this injury/illness?
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Whom did you see?
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Doctor’s Phone Number
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Date and Time
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Has this part of your body been injured before?
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When?
COMPLETION
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Your Signature
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Supervisor Signature
SUPERVISOR'S ACCIDENT INVESTIGATION
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Name of Injured Person
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Gender
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What part of the body was injured? (Describe in detail)
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What was the nature of the injury? (Describe in detail)
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Describe fully how the accident happened? What was employee doing prior to the event? What equipment or tools were being used?
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Names of all Witnesses: (Click "Add Witness")
Witness
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Name
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Date & Time of event
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Date & Time Reported
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Exact location of event
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What caused the event?
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Were safety regulations in place and used?
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What was wrong?
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Employee went to doctor/hospital?
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Recommended preventive action to take in the future to prevent reoccurrence.
COMPLETION
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Supervisor Signature
