Information

  • Audit Title

  • Document No.

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Personnel

SECTION I

  • Date and time of incident

  • Date and time incident was reported.

  • To whom was the incident reported?

  • Location of incident. (Specify site location)

  • Supervisor's Name

  • Supervisor's Phone Number

  • Was there any witness(es)? If yes, provide name(s).

PERSON(S) INVOLOVED

  • Name (Person 1):

  • Phone:

  • Sex:

  • Age;

  • Job Title:

  • Time on job: (Yrs & Mos)

  • Job Status:

  • Classification:

  • Employee Disposition Status:

  • Medication prescribed? If yes list medications.

NATURE OF INJURY

  • Describe injury.

  • Detail any first-aid or medical treatment administered. (Provide names)

  • Property Damage:

  • Photo of damage.

  • Property Damage:

  • Photo of damage.

  • Estimated cost of damage:

  • Vehicle ID:

  • Make/Model:

  • Age:

  • Equipment ID:

  • Model:

  • Age:

  • Detailed description of incident. (Include environmental conditions at time of incident)

  • Environmental photo:

  • Environmental photo:

  • Immediate (Direct Causes):

  • Direct cause photo:

  • Direct cause photo:

  • Contributing (underlying) Factors:

  • Contributing factors photo:

  • Corrective Action (Include detail description of action and person(s) responsible for actions)

  • What could have potentially happened?

  • What was the potential for severity?

  • What is the probability of reoccurrance?

  • Select date

  • Signature

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.