Information

  • Job #

  • Job Name

  • ViewPoint Reference #

  • Audit Title

  • Client / Site

  • Site Supervision:

  • Conducted on

  • Prepared by

  • Weather Condition:

  • Overall visibility

  • Location

Accident/Incident Details

  • Employee / Injured Party Name:

  • Is the injured party an employee of JMCC? If the answer is no, list Sub-Contractor or Affiliation to project.

  • Trade:

  • Indicate Employees Union Local affiliation:

  • Date and time of injury;

  • Describe nature of injury:

  • Describe what employee was doing at the time of injury:

  • Was employee working on assigned task? Give details.

  • Who assigned task to employee?

  • Was a Pre-Task / Tool box Talk training completed before work began? (Attach Copies)

  • Photograph copies of training documents (attach here)

  • What were fellow co-workers / trades assignment at the time of injury?

  • Were co-workers or other tradesmen present at time of injury? (List individually)

  • Were there any witnesses?

  • Witness Statement:

  • Witness

  • Witness Signature:

  • Witness

  • Witness signature:

  • Location of accident (please be specific)

  • Describe who, what, when,where, why and how injury occurred:

  • photo of work area

  • photo of task and body position

  • Photo of injury (if possible)

  • Were tools being carried or used at time of incident

  • Describe tools being used or carried at time of incident:

  • Did the use of tools, equipment or material play a role in this incident?

  • Describe how tools, equipment or material affected this incident:

  • Were photo's taken at time of incident by anyone else beside person completing this form?

  • Who took other photo's and what is their affiliation to the project? (Please List with contact info)

  • Contributing Cause or Causes of the incident: (Inadequate PPE, Not Paying attention to surroundings, failure to utilize safety equipment)

Injury Details if Applicable

  • Was first aid provided at time of injury?

  • Did employee decline medical treatment at time of injury?

  • Did injured employee go to clinic to receive medical attention for injury?

  • Name and Location of assigned facility.

  • Were any chemicals involved in incident?

  • Describe chemicals and photo label on can and photo of SDS (aka) MSDS for chemical.

  • Add media

  • What is the employee's current status if injured: Describe. ( Returned to work the next day, off of work due to injury, off of work due to restrictions, In hospital, etc.)

  • Was employee released to full / regular duty?

  • Was post accident drug testing performed?

  • Was the employee released to work with restrictions?

  • Describe in detail restrictions:

  • Is there a follow up appointment, if so when? (Select date & time)

  • Is there a light duty position available based on restrictions?

Action: Short Term

  • What was the immediate action taken to correct the issue (how was this done):

Action: Long Term

  • What are the long term action or actions needed to correct and avoid this issue? (describe)

Additional Information

  • Drawings applicable to Incident

  • Are there any attachments that apply: Pictures, Drawings, Training Records, Statement of Employee, Statement of Witness/es, Other.

  • Attachment Details here:

Person Completing Form (please sign below)

  • Investigation by:

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.