Information

  • Audit Title:

  • Document No.

  • Job Site Name:

  • Job Site Address:
  • Job Site Foreman's Name:

  • Date of Report:

  • Prepared By:

SECTION I - INCIDENT INFORMATION

  • Employee's Name:

  • Employee's Position:

  • Length of Employment:

  • Date and time of incident:

  • Day of the week

  • Date and time incident was reported:

  • Type of Incident:

  • To whom was the incident reported?

  • Location of incident. (Specify site location)

  • Weather Conditions:

  • Temperature:

SECTION 2 - DETAILS OF INJURY (IF APPLICABLE)

  • Was anyone injured? (If no, select N/A and skip to section 3)

  • Employee

  • Other

  • Describe what happened:

  • Photograph what injured individual

  • If employee, who assigned the task to the employee?

  • Type of work employee was doing at time of injury:

  • What was the employee doing when injured? (Be specific)

  • What was the employee instructed to do?

  • What is the normal procedure for completing the task?

  • What tools/equipment was the employee using?

  • What protective equipment was being used? If not why?

  • Nature of Injury:

  • Other:

  • Location of Injury:

  • What treatment did the employee receive:

  • Name and address of medical treatment facility

SECTION 3 - DETAILS OF PHYSICAL DAMAGE, IF APPLICABLE

  • Was there any physical damage to property, equipment or auto (if no, select N/A and proceed to section 4)

  • Describe what happened.

  • Insert drawing of damage location?

  • Drawing

  • Property Damage:

  • Photos of damage:

  • Vehicle or Equipment #1

  • Employee Name:

  • Passengers?

  • Names:

  • Make of Vehicle or Equipment:

  • Vehicle ID:

  • Vehicle or Equipment Damage:

  • Photos of Damage:

  • Vehicle or Equipment #2

  • Employee Name or Other Drivers Name:

  • Passengers?

  • Names:

  • Make of Vehicle or Equipment:

  • Vehicle or Equipment ID:

  • Vehicle/Equipment Damage:

  • Photos of Damage:

SECTION 4 - ROOT CAUSE ANALYSIS

  • Why did it happen? (Root Cause Analysis) - What was the root cause of the incident i.e. actually caused the illness, injury or accident?)

  • Was a JHA performed by the supervisor and documented?

  • Stretch and Flex performed today?

  • Who trained the employee on the hazards and protective measures for this task?

  • What training was given to employee?

  • What safety rules were in place to prevent this type of incident?

  • Was the supervisor within sight of the incident?

  • When had the supervisor last checked on progress?

  • Where was the supervisor at the time of the incident?

  • Unsafe Acts

  • Unsafe Acts (Other):

  • Unsafe Conditions

  • Unsafe Conditions (Other):

  • Management System Deficiencies

  • Management System Deficiencies (Other):

  • List immediate actions taken:

  • What should be done to prevent recurrence? (Be specific as to what would prevent the injury, incident or damage from occurring again)

  • Was the 3-Hour Safety Training completed?

SECTION 5 - STATEMENTS

  • Were there any witnesses to the incident?

  • Witness Statement

  • Signature of Witness

  • Witness Statement - (if photographed statement)

  • Employee Statement

  • Signature of Employee

  • Employee Statement - (if photographed statement)

SECTION 6 - REPORTED BY / DATE

  • Additional Comments:

  • Signature

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.