Information

  • Audit Title

  • Document No.

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Personnel

SECTION I

  • Name

  • Date and time of incident

  • Date and time incident was reported.

  • Approximate Length of employment, in months

  • Name and address of hospital, if applicable.
  • Photo of doctor's release note.

  • To whom was the incident reported?

  • Location of incident. (Specify site location)

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

  • Activity/ task engaged in at time of incident/ accident

  • Employee's normally assigned task

  • Related training received by employee

  • Date of training

DETAILS OF INJURY, IF APPLICABLE

  • Describe injury.

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

  • Immediate action taken

DETAILS OF DAMAGE, IF APPLICABLE

  • Property Damage:

  • Photo of damage.

  • Property Damage:

  • Photo of damage.

  • Vehicle ID:

  • Detailed description of incident. (Include environmental conditions at time of incident)

  • Environmental photo:

  • Immediate (Direct Causes):

  • Direct cause photo:

  • Direct cause photo:

ANALYSIS

  • 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?

  • Any previous, similar, or related incidents/ accidents

  • Date of previous incident

  • Actions taken to prevent this or similar incidents/ accidents

  • Any additional recommendations

  • Signature

  • Select date

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.