Incident Review's

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

Incident

• Date of Injury?

  Date

• What was the injury duration?

  Over period of time (OPT)

  Acute

  Uncertain

• What are the contributing mechanisms to the injury?

  Select Manual handling (lifting/pulling) Slip/trip Repetitive work Awkward postures (bending/twisting) Sustained positions Jarring/jerking

  • Manual handling (lifting/pulling)
  • Slip/trip
  • Repetitive work
  • Awkward postures (bending/twisting)
  • Sustained positions
  • Jarring/jerking

• What a experience does the worker have?

  0-1 Year

  1-5 Years

  5-10 Years

  +10 Years

  +20 Years

• Time into Shift

  Select 25% or less 26% -50% 51% - 75% 76% - 100% Over a period of time Overtime After Hours

  • 25% or less
  • 26% -50%
  • 51% - 75%
  • 76% - 100%
  • Over a period of time
  • Overtime
  • After Hours

• Injury/illness Actual

  Level 1

  Level 2

  Level 3

  Level 4

• Injury/illness Potential

  Level 1

  Level 2

  Level 3

  Level 4

• Signature of Auditor

  Sign