Information
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Audit Title
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Document No.
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Client / Site
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Conducted on
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Prepared by
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Location
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Personnel
SECTION I
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Date and time of incident
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Driver/Operator Name:
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Driver/Operator Credentials: (driver's license, OSHA card, etc.)
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Location of incident. (Specify site location)
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Was there any witness(es)? If yes, provide name(s).
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Was equipment inspected prior to use
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Inspection log for date of incident
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Pre-shift meeting (if applicable)
DETAILS OF INJURY, IF APPLICABLE
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Describe injury.
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Detail any first-aid or medical treatment administered. (Provide names)
DETAILS OF DAMAGE, IF APPLICABLE
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Property Damage:
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Photo of damage.
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Property Damage:
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Photo of damage.
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Vehicle Make:
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Vehicle Model:
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Detailed description of incident. (Include environmental conditions at time of incident)
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Photos of the scene:
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Immediate (Direct Causes):
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Direct cause photo:
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Direct cause photo:
ANALYSIS
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Contributing (underlying) Factors:
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Corrective Action (Include detail description of action and person(s) responsible for actions)
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What was the potential for severity?
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What could have potentially happened?
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Select date
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Signature