Category of Severity

Brief event description

First aid required?

Further medical attention (GP / Hospital) required?

Immediate medical attention accepted?

Well being (incident management / return to work)
pack provided?

D&A testing required?

Escalation & support:
Operations Manager notified?

Re-focus conducted?

People-soft entry scheduled (will be completed within

Problem solving: Fishbone required?

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.