Title Page
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Document No.
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Audit Title
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Client / Site / Project
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Report conducted on
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Prepared by
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Location
First Incident Details
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Date & Time of Incident
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Location of Incident
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Incident Priority?
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Site / Project Name
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Incident Type? (Spill, Injury, Accident, Property Damage, (if combination, list all))
- Near-Miss
- Slip & Fall
- Accident
- Injury
- Property Damage
- Spill
- Fatality
- Other
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Please describe type of incident
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Name of on-duty supervisor at time of incident?
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Is immediate medical attention required?
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What kind of medical attention was administered?
- First Aid
- Doctor Consulted
- Hospital
- Ambulance
- Medical Attention Declined
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Which of the following do you need to attach to this report to accuractly document this incident?
- Evidence
- Equipment Details
- Vehicle Details
- Damages
- Other Items
Evidence Log
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Please log all relevant evidence below
Evidence
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Evidence Description
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Evidence ID number (if applicable)
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Type of evidence
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Photos of evidence (if applicable)
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Please detail any further information regarding this evidence (if applicable)
Vehicle Log
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Please log all relevant vehicle details below
Vehicle
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Tractor #
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Trailer #
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Vehicle/Equipment Registration
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Driver (if applicable)
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Photos of equipment (if applicable)
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Please detail any further information regarding this vehicle (if applicable)
Damage Log
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Please log all relevant damage details below
Damage
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Damage description
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Photos of damage (if applicable)
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Please detail any further information regarding this damage (if applicable)
Other Items Log
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Please log all relevant details of other items below
Item
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Item description
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Photos of item (if applicable)
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Please detail any further information regarding this item (if applicable)
Equipment Log
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Please log all relevant equipment details below
Equipment
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Tractor #
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Trailer #
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Photos of equipment (if applicable)
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Please detail any further information regarding this equipment (if applicable)
Record Evidence and Information
People involved
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Please document all people involved in this incident, including yourself (the person reporting the incident)
Person
Person
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Full Name
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Contact phone number
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What is this person's relation to the incident? (select all that apply)
- Reporter of incident
- Injured person
- Witness
- Primary person involved
- Secondary Involvement
- On-duty supervisor
- Investigator
- Suspect
- Other
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Describe this person's relation to the incident
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Please describe this person's involvement with the incident, including all relevant information
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Does this person wish to make a preliminary statement?
Preliminary Statement
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Statement regarding incident
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Person Signature
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Has this person sustained an injury?
Injury Details
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Type of injury or illness? (select all that apply)
- Superficial
- Open Wound
- Fatality
- Concussion
- Sprain
- Respiratory
- Eye Injury
- Burns
- Fracture
- Electrocution
- Fall
- Strain
- Dislocation
- Struck by object
- Entanglement
- Assault
- Muscle & Tendon
- Nerve & spinal cord
- Amputation
- Intracranial
- Other Injury
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Describe type of injury or illness
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Parts of body affected? (select all that apply)
- General Ailment
- Head
- Eye (Left)
- Eye (Right)
- Ear
- Nose
- Throat
- Neck
- Back (Upper)
- Back (Lower)
- Arm - Upper (Right)
- Arm - Upper (Left)
- Arm - Elbow (Right)
- Arm - Elbow (Left)
- Arm - Forearm (Right)
- Arm - Forearm (Left)
- Wrist (Right)
- Wrist (Left)
- Hand (Right)
- Hand (Left)
- Chest
- Abdominal / Stomach
- Groin / Anus
- Leg - Upper (Right)
- Leg - Upper (Left)
- Leg - Knee (Right)
- Leg - Knee (Left)
- Leg - Lower (Right)
- Leg - Lower (Left)
- Ankle (Right)
- Ankle (Left)
- Foot (Right)
- Foot (Left)
- Shoulder (Left)
- Shoulder (Right)
- Other
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Please describe injury location
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Describe this injury or illness
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What was the cause of this injury or illness?
Describe the sequence of events
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This is an example of how to describe the sequence of events.
1. Produce a Sequence of Events
Once you have gathered statements, pictures and any other relevant information, a Sequence of Events, combined with any Conditions helps tremendously in determining Root Causes and establishing appropriate Corrective Actions.
Start with a simple sequence to show What happened:
1. Pulled into site.
2. Parked in designated area.
3. Checked in with rig manager.
4. Got back in truck.
5. Backed out and caught bumper of another vehicle.
6. Reported incident to Rig Manager and Area Manager
Add in the Conditions that may have contributed to those events:
1. Pulled into site.
∞ Designated parking area.
∞ Snowing heavily, site was very slippery.
2. Parked in designated area.
∞ Drove straight in; didn’t back in – wasn’t a requirement at this site.
3. Checked in with rig manager.
∞ Went over equipment problems and what needed to be fixed immediately.
∞ Had to move truck closer to equipment.
4. Got back in truck.
∞ Pre-occupied with the repair job that was required.
∞ Still snowing heavily and didn’t look closely at the other vehicles that had parked since arriving.
5. Backed out and caught bumper of another vehicle.
∞ Didn’t look around vehicle before backing.
∞ Snow on side mirrors and back window was not cleared off.
∞ Other vehicle was parked close and at an angle.
∞ Was pressured to get equipment fixed quickly.
6. Reported incident to Rig Manager and Area Manager -
Describe what happened. Please be detailed but state only facts. Keep in mind any communication that occurred before the incident and policies and procedures to complete task at hand.
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What were the weather / environmental conditions at the time of the incident?
- Clear
- Cloudy
- Rain
- Snow
- Windy
- Heatwave
- Haze
- Other
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Describe the weather / environmental conditions at the time of the incident
IMMEDIATE Corrective Actions to Employees/Contractor, Equipment, Location, or Property
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This is any IMMEDIATE corrective action that is required before root cause and responsibility is determined. An example of IMMEDIATE corrective action would be moving the cascade with bottles from behind the tank battery to next to stairs, in view of the driver.
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Are immediate corrective actions required with regard to this incident?
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Have all required corrective actions been added as Actions to this inspection?
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Please add any corrective actions to the appropriate questions above before completing this incident report
Sign Off
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Further action/follow-up/investigation required?
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Name of person/people to follow up
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Name & Signature of Reporter
