Investigation [Sample template]

• Welcome to the inspection experience on SafetyCulture!
  
  Everything you see in this sample inspection experience can be customized using the Template Editor.
  
  This page is the title page, which is the first page you see when you conduct a new inspection or view an inspection report.
  
  Title pages are a great way to capture essential details, giving you high-level context to inspection results.

• Document No.

• Client / Site / Project

• Report conducted on

  Date

• Prepared by

• Location
  Address

First incident details

• Date & Time of Incident

  Date
• Location of Incident
  Address

• Incident Priority?

  Urgent

  High

  Medium

  Low

  Trivial

• Incident Type?

  Select Hazard Near-Miss Slip & Fall Accident Injury Theft Fire Property Damage Fatality Illness Other Reportable / Notifiable Loss Time

  • Hazard
  • Near-Miss
  • Slip & Fall
  • Accident
  • Injury
  • Theft
  • Fire
  • Property Damage
  • Fatality
  • Illness
  • Other
  • Reportable / Notifiable
  • Loss Time

• Please describe type of incident

• Name of on-duty supervisor at time of incident?

• Is immediate medical attention required?

  Yes

  No

• What kind of medical attention was administered?

  Select First Aid Doctor Consulted Hospital Ambulance Medical Attention Declined

  • First Aid
  • Doctor Consulted
  • Hospital
  • Ambulance
  • Medical Attention Declined

Describe What Happened

• Describe what happened. Please be detailed but state only facts.

• What were the weather / environmental conditions at the time of the incident?

  Select Clear Cloudy Rain Snow Windy Heatwave Haze Other

  • Clear
  • Cloudy
  • Rain
  • Snow
  • Windy
  • Heatwave
  • Haze
  • Other

• Describe the weather / environmental conditions at the time of the incident

Record Evidence and Information

• Which of the following do you need to attach to this report to accuractly document this incident?

  Select Evidence Equipment Details Vehicle Details Damages Other Items

  • Evidence
  • Equipment Details
  • Vehicle Details
  • Damages
  • Other Items

Evidence

• Evidence Description

• Evidence ID number (if applicable)

• Type of evidence

  Document

  Photos

  Other

• Photos of evidence (if applicable)

  Media

• Please detail any further information regarding this evidence (if applicable)

People involved

• Please document all people involved in this incident, including yourself (the person reporting the incident)

Person

Person

• Full Name

• ID number

• Contact phone number

Follow up tasks

• Are corrective/further actions required with regard to this incident?

  Yes

  No

Sign Off

• Further action/follow-up/investigation required?

  Yes

  No

• Name of person/people to follow up

• Name & Signature of Reporter

  Sign

• Yes

  No

  N/A