Information
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Audit Title
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Job #
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Conducted on
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Prepared by
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Foreman:
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Type of Incident:
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Division
Accident Information
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Name of Employee(s):
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Date and time of incident:
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Date and time incident was reported:
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To whom was the incident reported?
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Location of incident. (Specify site location):
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Was there any witness(es)?
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Dustrol Employee:
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Name(s):
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Address, City, State, Zip:
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Phone(s):
DETAILS OF INJURY, IF APPLICABLE
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Describe in detail what caused the accident and what the employee was doing when the injury occurred:
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Detail of injuries including body part and severity:
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Describe equipment, material, or chemicals in use at time of injury:
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Were safeguards or safety equipment provided?
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What were they and were they used?
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Why not?
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Name of Clinic/Hospital:
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Phone number(s) for Clinic/Hospital:
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Address of Clinic/Hospital (City/State/Zip):
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Stitches required:
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How many?
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X-Rays taken:
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Results of x-ray:
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Drugs prescribed or given:
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Name and MGS:
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Drug Screen:
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Why not:
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Results:
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Why:
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Did employee receive full pay for the day of injury?
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Please detail amount of work credited to employee:
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Restrictions?
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Detail restrictions:
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Lost days?
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How many:
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Date & Time employee returned to work:
Dustrol Property/Vehicle Damage Details
DETAILS OF DAMAGE, IF APPLICABLE
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Property Type:
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Please provide detailed description of other property:
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Vehicle/Equipment ID:
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What was the cause of the incident:
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Direct cause photo:
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Detailed description of entire incident:
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Photos to help describe incident:
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Detailed "inventory" of equipment, vehicles, other property involved:
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Photos of "inventory" involved, including photo of the general scope of the incident:
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Were authorities notified:
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City Police/Sheriff/Hwy Patrol?
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Name of jurisdiction (Name of City/County/Etc...):
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Name of jurisdiction (Name of City/County/Etc...):
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Name of jurisdiction (Name of City/County/Etc...):
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Name/Badge number of officer
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Police Report number:
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Citation(s) Issued:
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Please list citations:
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Date & Time foreman notified:
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Date & Time information received:
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Why not?
Other Property/Vehicle Information
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Driver(s) Name:
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Driver's License Number/State/D.O.B.:
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Street Address/City/State/Zip:
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Phone:
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Number
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Number:
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Number:
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Hours to call between:
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Owner of Vehicle:
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Make/Model/Year/Tag of vehicle:
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Description of Damage:
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Driver's Insurance Carrier:
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Policy #:
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Insurance Agent and Phone Number:
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Passenger(s):
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Name(s) of Injured and Extent of Injuries:
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Anyone transported by ambulance:
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Taken Where:
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Witnesses:
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Name, Address, Phone Numbers:
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Other Information:
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Any additional photos:
