Incident Report

• Audit Title

• Document No.

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

SECTION I

• Date and time of incident

  Date

• Date and time incident was reported.

  Date

• To whom was the incident reported?

• Location of incident. (Specify site location)

• manager on Duty

• Premises Contact Phone

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

  Yes

  No

  N/A

PERSON(S) INVOLOVED

• Name (Person 1):

• Phone:

• Sex:

  Male

  Female

• Age;

• Classification:

  Select Employee Contractor Customer

  • Employee
  • Contractor
  • Customer

• Job Title:

• Time on job: (Yrs & Mos)

• Employee Disposition Status:

  Select On duty Off duty

  • On duty
  • Off duty

• Medication prescribed? If yes list medications.

  Yes

  No

  N/A

NATURE OF INJURY

• Describe injury.

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

• Property Damage:

  Select None Minor Major

  • None
  • Minor
  • Major

• Photo of damage.

  Media

• Property Damage:

  Select None Minor Major

  • None
  • Minor
  • Major

• Photo of damage.

  Media

• Equipment ID:

• Model:

• Age:

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

• Environmental photo:

  Media

• Environmental photo:

  Media

• Immediate (Direct Causes):

• Direct cause photo:

  Media

• Direct cause photo:

  Media

• Contributing (underlying) Factors:

• Contributing factors photo:

  Media

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

• What could have potentially happened?

• What is the probability of reoccurrance?

  Select None Minor Major

  • None
  • Minor
  • Major

• Select date

  Date

• Signature

  Sign