Information

  • Audit Title

  • Document No.

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Personnel

General Information

  • Date and time of incident

  • Date and time incident was reported.

  • To whom was the incident reported?

  • Supervisor's Name

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

PERSON(S) INVOLOVED

  • Name (Person 1):

  • Sex:

  • Phone:

  • Age;

  • Job Title:

  • Time on job: (Yrs & Mos)

  • Employee Disposition Status:

  • Medication prescribed? If yes list medications.

Enter witness #1 statement

  • Add signature

Enter witness #2 statement

  • Add signature

Enter witness #3 statement

  • Add signature

  • Add signature

NATURE OF INJURY

  • Describe injury.

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

  • Was there any Property Damage?

  • Photo of damage.

  • Any equipment involved?

  • We're there any vehicles involved?

  • Model:

  • Was any equipment involved?

  • Equipment Asset number:

Describe Incident

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

  • Environmental photo:

  • Immediate (Direct Causes):

  • Direct cause photo:

  • Contributing (underlying) Factors:

  • Contributing factors photo:

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

  • What was the potential for severity?

  • What could have potentially happened?

  • What is the probability of reoccurrance?

  • Name of Investigator

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. Any ratings or scores displayed in our Public Library have not been verified by SafetyCulture for accuracy. Users of our platform may provide a rating or score that is incorrect or misleading. You should independently determine whether the template is suitable for your circumstances. You can use our Public Library to search based on criteria such as industry and subject matter. Search results are based on their relevance to your search and other criteria. We may feature checklists based on subject matters we think may be of interest to our customers.