Title Page

  • Document No.

  • Audit Title

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Personnel

Personal and Incident Details

  • Full Name

  • Date of Birth

  • Sex

  • Occupation

  • Contact number

  • Home address

  • Email address

Injury Details

  • Type of injury or disease (e.g burn)

  • Part/s of the body affected

  • Date and Time of symptoms

  • Was medical treatment given?

  • Treatment provided

  • Provider

  • Date and Time of treatment

  • Time lost due to injury?

  • How many hours/days?

  • How did the injury happen?

Investigation

  • How long had you been working prior to the incident?

  • How long had you been working on this task?

  • Is this task part of your normal duties?

  • Have you been trained for this task?

  • What were you doing in the time prior to the incident?

  • Are there any other factors involved (e.g management, work environment, equipment) involved?

  • What do you think could have been done to prevent this from occuring?

  • Other comments or observations

  • What sort of injury occurred?

  • Type of injury?

  • Safe Work Method Statements followed?

  • Equipments/objects/insects involved?

  • Equipment in good condition?

  • Date of last service of equipment

  • Appropriate safety equipment used?

  • Lighting adequate?

  • Housekeeping issues contributed?

  • Surface type

  • Type of shoes worn

  • Workload excessive?

  • Workload boring and repetitive?

  • Is it a slip or trip?

  • Height of fall

  • Were you -

  • If stairs -

  • Did you fall on your -

  • What were you carrying (if anything) at that time?

  • Does it involve manual handling?

  • Were your items within easy reach?

  • Ergonomic equipment available?

  • Was the equipment being used correctly?

  • Repititive and forceful movements used?

  • Action involved

  • Weight of object

  • Distance carried/position of object moved from/to

  • Height of load

For the WHS Manager

  • Comments and Observation

  • Recommendation

  • Person assigned

  • Target Date

Supervisor or WHS Manager Notification

  • Supervisor

  • WHS Manager

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. You should independently determine whether the template is suitable for your circumstances.