Incident Report

• Audit Title

• Document No.

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

General Information

• Date and time of incident

  Date

• Date and time incident was reported.

  Date

• To whom was the incident reported?

• Supervisor's Name

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

  Yes

  No

  N/A

PERSON(S) INVOLOVED

• Name (Person 1):

• Sex:

  Male

  Female

• Phone:

• Age;

• Job Title:

• Time on job: (Yrs & Mos)

• Employee Disposition Status:

  returned to work

  minor first aid by employee

  Sent to Work Health

  Sent to ER

  Hospitalized

• Medication prescribed? If yes list medications.

  Yes

  No

  N/A

Enter witness #1 statement

• Add signature

  Sign

Enter witness #2 statement

• Add signature

  Sign

Enter witness #3 statement

• Add signature

  Sign

• Add signature

  Sign

NATURE OF INJURY

• Describe injury.

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

• Was there any Property Damage?

  yes

  no

• Photo of damage.

  Media

• Any equipment involved?

  yes

  no

• We're there any vehicles involved?

  Yes

  No

  N/A

• Model:

• Was any equipment involved?

  Yes

  No

  N/A

• Equipment Asset number:

Describe Incident

• Detailed description of just prior to and incident. (Include environmental conditions at time of incident)

• Environmental photo:

  Media

• Immediate (Direct Causes):

• 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 was the potential for severity?

  slight

  minimal

  serious

  fatal

• What could have potentially happened?

• What is the probability of reoccurrance?

  Select unlikely probable

  • unlikely
  • probable

• Name of Investigator

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