Information

  • Site conducted

  • Document No.

  • Audit Title

  • Client / Site

  • Conducted on

  • Investigation Status

  • Prepared by

  • Investigation Team

Incident Occurance

  • Date And Time The Incident Occurred/Discovered:

  • Date And Time The Incident Was Reported:

  • Customer and Project:

  • Incident Location:

Incident Classification

  • Information Report / Non-Work Related

  • Near Miss

  • Spill / Release

  • Is the spill reportable? (More than 5bbl of liquid.)

  • Estimate Amount Spilled:

  • Property Damage

  • Minor = Valued less than $5000.00 / Major = Valued more than $5000.00

  • Injury

  • Injury Classification:

Employee Information

  • Employee Information:

  • Employee
  • Employee's Full Name

  • Employee Trade

  • Employee ID Number:

  • Employee Gender:

  • Employee's Date Of Birth:

  • Short Service Employee?

  • Employee's Phone Number:

  • Injury / Illness

  • Describe the location and nature of the injury:

  • Was Axiom Contacted?

  • Describe Treatment:

  • Was the Employee taken to a Medical Clinic or Hospital?

  • Name, Location, and phone number of the Clinic.

  • Name of the attending Physician.

  • Was prescription medication administered or given?

  • Was the employee released to full duty? (If not, list restrictions)

Property Damage

  • Property Damage

  • Property
  • Property Owner's Information:

  • Description of property and damage:

  • Vehicle Damage

  • Vehicle
  • Vehicle Owner:

  • Vehicle Owner's Information:

  • Vehicle Description (Y/M/M):

  • Describe Vehicle Damage:

  • Equipment Damage

  • Equipment
  • Manufacturer:

  • Equipment Type:

  • Equipment Number:

  • Describe Damage:

Utility Damage

  • Utility Damage

  • Utility
  • Type of Utility:

  • Is the line regulated by the DOT?

  • Depth of damaged utility line:

  • Utility Owner:

  • Cable / Line Size:

  • Were Locates Requested?

  • Was the "One Call" Current?

  • One-Call Ticket Number:

  • One-Call Emergency Dig Up Ticket Number:

  • Check Damage Prevention Service:

  • Was The Utility Located?

  • Were The Locates Correct?

  • Was a "Blind Sweep" conducted?

  • We're all customer required permits completed?

Description Of Events

  • Brief Description Of Incident:

  • Additional Investigation Information:

  • Causes Or Factors:

  • Preventative Measures:

  • Preventative Measures:

  • Attach Photos:

  • Photo Notes:

  • Diagrams:

Close Out

  • Auditor Name:

  • Auditor Signature

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.