Audit

First Incident Details
Date & Time of Incident
Location of Incident

Incident Priority?

Site / Project Name

Incident Type?

Please describe type of incident

Name of on-duty supervisor at time of incident?

Is immediate medical attention required?

What kind of medical attention was administered?
Describe What Happened

Describe what happened. Please be detailed but state only facts.

What were the weather / environmental conditions at the time of the incident?

Describe the weather / environmental conditions at the time of the incident

Record Evidence and Information
Which of the following do you need to attach to this report to accuractly document this incident?
Evidence Log

Please log all relevant evidence below

Evidence

Evidence Description

Evidence ID number (if applicable)

Type of evidence

Photos of evidence (if applicable)

Please detail any further information regarding this evidence (if applicable)

Vehicle Log

Please log all relevant vehicle details below

Vehicle

Vehicle Make

Vehicle Model

Vehicle Registration

Driver (if applicable)

Photos of equipment (if applicable)

Please detail any further information regarding this vehicle (if applicable)

Damage Log

Please log all relevant damage details below

Damage

Damage description

ID number (if applicable)

Photos of damage (if applicable)

Please detail any further information regarding this damage (if applicable)

Other Items Log

Please log all relevant details of other items below

Item

Item description

ID number (if applicable)

Photos of item (if applicable)

Please detail any further information regarding this item (if applicable)

Equipment Log

Please log all relevant equipment details below

Equipment

Equipment Make

Equipment Model

Equipment ID number (if applicable)

Photos of equipment (if applicable)

Please detail any further information regarding this equipment (if applicable)

People involved

Please document all people involved in this incident, including yourself (the person reporting the incident)

Person
Person

Full Name

ID number

Contact phone number

What is this person's relation to the incident? (select all that apply)

Describe this person's relation to the incident

Please describe this person's involvement with the incident, including all relevant information

Does this person wish to make a preliminary statement?

Preliminary Statement

Statement regarding incident

Person Signature

Has this person sustained an injury?

Injury Details
Type of injury or illness? (select all that apply)

Describe type of injury or illness

Parts of body affected? (select all that apply)

Please describe injury location

Describe this injury or illness

What was the cause of this injury or illness?

Corrective Actions

Are corrective/further actions required with regard to this incident?

Have all required corrective actions been added as Actions to this inspection?

Please add any corrective actions to the appropriate questions above before completing this incident report

Sign Off

Further action/follow-up/investigation required?

Name of person/people to follow up

Name & Signature of Reporter