Title Page
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Document No.
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Audit Title (brief description)
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Client / Site / Project / Personnel
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Persons Involved
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Report conducted on
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Prepared by
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Time of investigation
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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Incident Type?
- First Aid
- Doctor Consulted
- Hospital
- Ambulance/ 911
- Medical Attention Declined
- After the Fact Medical Attention
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Forman of shift
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Superintendent of Project
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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/ 911
- Medical Attention Declined
- After the Fact Medical Attention
Describe What Happened
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Describe what happened. Please be detailed, but state only facts.
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What were the weather / environmental conditions at the time of the incident?
- Clear
- Cloudy
- Rain
- Snow
- Windy
- Heatwave
- Haze
- Extreme Warm at Location temperature ?
- Extreme Cold at location temperature ?
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Describe the weather / environmental conditions at the time of the incident?
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Were blood born pathogen protocols followed?
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Is training and deacon procedures needed
Record Evidence and Information
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Which of the following do you need to attach to this report to accuractly document this incident?
- Evidence
- Equipment Damage
- Vehicle Damage
- Damages Other
- Reasonable Suspicion
- Near Miss
- Media
- 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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Vehicle Make
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Vehicle Model
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Vehicle 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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ID number (if applicable)
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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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ID number (if applicable)
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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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Equipment Make
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Equipment Model
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Equipment ID number (if applicable)
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Photos of equipment (if applicable)
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Please detail any further information regarding this equipment (if applicable)
People involved
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Please document all people involved in this incident, including yourself (the person reporting the incident)
Person
Person (Other than the primary involved / witness / helper / co worker)
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Full Name
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Contact phone number (if available)
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What is this person's relation to the incident? (select all that apply)
- Reporter of incident
- Injured person
- Witness
- Secondary Involvement
- On-duty supervisor
- Investigator
- Suspect
- Helper at incident
- Other
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Describe this person's relation to the incident
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Other description
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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 if capable
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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
- Crushing
- 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?
Corrective Actions
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Are corrective / further 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 Investigator
