Audit
- Urgent
- High
- Medium
- Low
- Trivial
Site / Project Name
- Hazard
- Near-Miss
- Slip & Fall
- Accident
- Injury
- Theft
- Fire
- Property Damage
- Fatality
- Illness
- Reportable / Notifiable
- Loss Time
- Other
Name of on-duty supervisor at time of incident?
Was medical attention administered?
Describe what happened. Please be detailed but state only facts.
Do you wish to include a timeline of events for this incident?
Event Description
- Clear
- Cloudy
- Rain
- Snow
- Windy
- Heatwave
- Haze
- Other
- Evidence
- Equipment Details
- Vehicle Details
- Damages
- Other Items
Evidence Description
Evidence ID number (if applicable)
- Document
- Photos
- Other
Please detail any further information regarding this evidence (if applicable)
Vehicle Make
Vehicle Model
Vehicle Registration
Driver (if applicable)
Please detail any further information regarding this vehicle (if applicable)
Damage description
ID number (if applicable)
Please detail any further information regarding this damage (if applicable)
Item description
ID number (if applicable)
Please detail any further information regarding this item (if applicable)
Equipment Make
Equipment Model
Equipment ID number (if applicable)
Please detail any further information regarding this equipment (if applicable)
Full Name
ID number
Contact phone number
- Reporter of incident
- Injured person
- Witness
- Primary person involved
- Secondary Involvement
- On-duty supervisor
- Investigator
- Suspect
- Other
Please describe this person's involvement with the incident, including all relevant information
Do you want to log a statement for this person?
Has this person sustained an injury?
- 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
- General Ailment
- Head
- Eye (Right)
- Eye (Left)
- 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 (Right)
- 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
Describe this injury or illness
What was the cause of this injury or illness?
Are corrective/further actions required with regard to this incident?
- Equipment Defects
- Unauthorized Equipment Use
- Improper Equipment Use
- Lack of protective safety devices
- Employee operating at inappropriate speed
- Equipment used outside rated capacity
- Lack of PPE
- Inappropriate PPE
- Untidy Conditions (Poor Housekeeping)
- Safety procedures not followed
- Inadequate ventilation
- Drugs or Alcohol
A Root Cause Analysis (RCA) is the process of determining the cause of an incident. It requires consideration of all the factors that may have contributed to this incident occurring and deeply understanding the underlying cause. One tactic to determine this is through asking "Why?" five times, to uncover the core of a problem.
Has the root cause of this issue been able to be identified?
Further action/follow-up/investigation required?
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Industry: Construction |
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