Injury, Accident, Incident Report

• Audit Title

• Document No.

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

SECTION I

• Name of Injured Person

• Occupation of Injured Person

• Date and time of incident

  Date

• Date and time incident was reported.

  Date

• To whom was the incident reported?

• Location of incident. (Specify site location)

• Main Contractor Details? Subcontractor Details?

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

  Yes

  No

  N/A

DETAILS OF INJURY, IF APPLICABLE

• Describe your observations of the injury & location on the body

• Was hospital treatment required? if yes what hospital?

• Was first aid administered? If yes by whom?

Injury Details

• Please attach photos of the injury if possible?

  Media

• Please detail in as much possible , what happened and how the accident occurred? (Who, what, where, when, why)

• Was there any plant, machinery or tooling in use when the accident occured?

Witness Details

• Name, occupation, and contact details of witness (1)

• Witness statement of accident/incident/near miss (who, what, where, when, why)

• Signature of witness

  Sign

• Name, occupation, and contact details of witness (2)

• Witness statement of accident/incident/near miss (who, what, where, when, why)

• Signature of Witness (2)

  Sign

• Was there a delay in reporting the accident/incident? if yes please state why?

  Yes

  No

  N/A

• Please include any Induction, safe pass or any other relevant training records.

  Yes

  No

  N/A

• PPE requirements?

  Select Safety Glasses Safety Gloves Safety Goggles Visor RPE Safety Hat Safety Boots Hi-visibilty Vest Harness & Lanyard

  • Safety Glasses
  • Safety Gloves
  • Safety Goggles
  • Visor
  • RPE
  • Safety Hat
  • Safety Boots
  • Hi-visibilty Vest
  • Harness & Lanyard

• PPE Compliance

  Compliant

  Non-Compliant

  N/A

DETAILS OF DAMAGE, IF APPLICABLE

• Property Damage:

  None

  Minor

  Serious

  Major

• Photo of damage.

  Media

• Details of Property Damaged

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

• Environmental photo:

  Media

ANALYSIS

• Details of Unsafe Act

• Details of Unsafe Condition

• Contributing (underlying) Factors:

• Contributing factors photo:

  Media

• Corrective Action (Include detail description of action and person(s) responsible for actions)

• Date by which corrective actions should implemented?

  Date

• What was the potential for severity?

  Minor

  Serious

  Major

• What could have potentially happened?

• What is the probability of reoccurrance?

  Remote

  Improbable

  Probable

• Please insert any other information which may be necessary?

• Please insert any images which may be necessary?

  Media

• Signature of Injured Person(s)

  Sign

• Signature of Injured Person(s)

  Sign

• Signature of Person Investigating

  Sign

• Signature of Witness 1

  Sign

• Signature of Witness 2

  Sign

• Signature of First Aider

  Sign