Title Page
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Document No.
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Audit Title
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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
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Employee ID#:
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Dept/Division:
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Job Position:
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Date of Accident:
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Employee Name:
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Time of Accident (AM, PM):
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Location:
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Type of Injury:
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Part of Body Injured:
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Employee's Supervisor:
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Detail Description of Accident:
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Eye witness:
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Environmental Conditions that may have contributed to the accident (weather, housekeeping, noise, light, etc.):
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Underlying factors contributing to accident (not wearing PPE, faulty equipment, lack of training, non-attentive, etc.):
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Corrective Actions to be taken (provide(d) training/tools, repair/replace, job procedures, work order, etc.):
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Add media
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Investigator's Name:
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Safety Coordinator/Safety Designee:
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Director/Asst. Director:
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