Information
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Site conducted
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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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Investigation Status
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Prepared by
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Investigation Team
Incident Occurance
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Date And Time The Incident Occurred/Discovered:
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Date And Time The Incident Was Reported:
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Customer and Project:
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Incident Location:
Incident Classification
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Information Report / Non-Work Related
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Near Miss
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Spill / Release
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Is the spill reportable? (More than 5bbl of liquid.)
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Estimate Amount Spilled:
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Property Damage
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Minor = Valued less than $5000.00 / Major = Valued more than $5000.00
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Injury
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Injury Classification:
- Minor First Aid
- First Aid
- Recordable
- Restricted Duty
- Lost Time
Employee Information
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Employee Information:
Employee
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Employee's Full Name
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Employee Trade
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Employee ID Number:
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Employee Gender:
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Employee's Date Of Birth:
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Short Service Employee?
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Employee's Phone Number:
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Injury / Illness
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Describe the location and nature of the injury:
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Was Axiom Contacted?
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Describe Treatment:
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Was the Employee taken to a Medical Clinic or Hospital?
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Name, Location, and phone number of the Clinic.
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Name of the attending Physician.
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Was prescription medication administered or given?
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Was the employee released to full duty? (If not, list restrictions)
Property Damage
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Property Damage
Property
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Property Owner's Information:
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Description of property and damage:
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Vehicle Damage
Vehicle
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Vehicle Owner:
- Main Office
- Toyah
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Vehicle Owner's Information:
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Vehicle Description (Y/M/M):
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Describe Vehicle Damage:
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Equipment Damage
Equipment
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Manufacturer:
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Equipment Type:
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Equipment Number:
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Describe Damage:
Utility Damage
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Utility Damage
Utility
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Type of Utility:
- Electrical Line
- Telephone Line
- Television Cable
- Fiber Optic Line
- Pipeline (Gas/Oil)
- Water Line
- Sewer Line
- Other
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Is the line regulated by the DOT?
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Depth of damaged utility line:
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Utility Owner:
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Cable / Line Size:
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Were Locates Requested?
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Was the "One Call" Current?
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One-Call Ticket Number:
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One-Call Emergency Dig Up Ticket Number:
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Check Damage Prevention Service:
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Was The Utility Located?
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Were The Locates Correct?
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Was a "Blind Sweep" conducted?
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We're all customer required permits completed?
Description Of Events
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Brief Description Of Incident:
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Additional Investigation Information:
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Causes Or Factors:
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Preventative Measures:
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Preventative Measures:
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Attach Photos:
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Photo Notes:
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Diagrams:
Close Out
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Auditor Name:
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Auditor Signature