GO DIGITAL TODAY Convert your paper checklists into digital forms
Scan this QR code to use this paper checklist on your smartphone or tablet. Visit www.iauditor.com
Audit
General Information:
Date of Incident:
Date of Report:
Name of Employee:
Employee Number:
Location of Incident:
Division:
Incident Type:
Personal Injury:
Full Details of Incident:
List of Injuries:
Suggestions for Preventing Incidents of this Type:
Were there witnesses to this incident?
Witness Name:
Witness Phone Number:
Witness Name:
Witness Phone Number:
Were actions taken as a result of this Incident?
Actions taken with the worker as a result of this Incident:
Training completed as a result of this incident:
Names of workers trained
Were there any injuries as a result of this incident?
Names of those injured:
Medical Treatment required?
When?
Where?
Dr. C. W. Wiebe Clinic
Boundary Trails Health Centre
Other
Name of Healthcare Practitioner or Healthcare Facility where medical treatment was received:
Name of doctor / healthcare practitioner:
I certify that, to the best of my knowledge, the above information is true and complete
Signature of Employee:
I certify that, to the best of my knowledge, the above information is true and complete
Signature of Manager:
Theft:
Was a Kroeker Farms Vehicle or Piece of Equipment stolen?
Unit Number:
Year:
License Number:
Estimated Damage:
Actual Damage:
Make:
Serial Number (if no Unit Number):
Full Details of the Incident:
List of Damages or Injuries:
Suggestions for Preventing Incidents of this Type:
Were there Witnesses to this Incident?
Witness Name:
Witness Phone Number:
Witness Name:
Witness Phone Number:
Was this Incident Reported to the police?
Select date
Was this Incident Reported to the Insurance Company?
Select date
I certify that, to the best of my knowledge, the above information is true and complete
Signature of Employee:
I certify that, to the best of my knowledge, the above information is true and complete
Signature of Manager:
Vandalism:
Was a Kroeker Farms vehicle or piece of Equipment Vandalized?
Unit Number:
Year:
License Number:
Estimated Damage:
Actual Damage:
Make:
Serial Number (if no Unit Number):
List of Damages or Injuries:
Suggestions for Preventing Incidents of this Type:
Full Details of Incident:
Were there any Witnesses to this Incident?
Witness Name:
Witness Phone Number:
Witness Name:
Witness Phone Number:
Was this Incident Reported to the Police?
Select date
Was this Incident Reported to the Insurance Company?
Select date
I certify that, to the best of my knowledge, the above information is true and complete
Signature of Employee:
I certify that, to the best of my knowledge, the above information is true and complete
Signature of Manager:
Accidental Damage:
Was a Kroeker Farms Vehicle or Piece of Equipment Damaged?
Unit Number:
Year:
License Number:
Estimated Damage:
Actual Damage:
Make:
Serial Number (if no Unit Number)
Full Details of this Incident:
List of Damages and / or Injuries:
Suggestions for Preventing Incidents of this Type:
Was there Another Party Involved in this Incident?
Other Party's Name:
Other Party's Phone Number:
Make:
Serial Number:
Year:
License Number:
Estimated Damage:
Actual Damage:
Were there any Witnesses to this Incident?
Witness Name:
Witness Phone Number:
Witness Name:
Witness Phone Number:
Were actions taken as a result of this Incident?
Action taken with the Worker as a result of this Incident:
Training Completed as a Result of this Incident:
Names of Workers Trained
I certify that, to the best of my knowledge, the above information is true and complete
Signature of Employee:
I certify that, to the best of my knowledge, the above information is true and complete
Signature of Manager:
Close Calls:
Was there a Kroeker Farms Vehicle or Piece of Equipment Involved I this Incident?
Unit Number:
Year:
License Number:
Estimated Damage:
Actual Damage:
Make:
Serial Number (if no Unit Number):
Full Details of this Incident:
List of Damages or Injuries:
Suggestions for Preventing Incidents of this Type:
Were any actions taken as a result of this Incident?
Action taken with the worker as a result of this Incident:
Training completed as a result of this Incident:
Names of Workers trained:
I certify that, to the best of my knowledge, the above information is true and complete
Signature of Manager:
I certify that, to the best of my knowledge, the above information is true and complete
Signature of Employee:
Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to
take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment;
or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is
permissible in your workplace or jurisdiction.
©SafetyCulture2019
