Title Page
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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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Everyone on the job site drops everything to address incident
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Type of incident
- no first aid required
- first aid required/administered
- advocate occupational health visit required
- emergency room visit required
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If no first aid required or first aid required, complete below section, if advocate occupational health visit or emergency room visit requires skip to next section
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Brief description of incident: - what happened - what actions were taken by Jondec Painting
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Follow up needed?
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Description of follow up needed if applicable
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Pictures if applicable
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If advocate occupational health visit or emergency room visit is required complete section below
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Description of incident
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Nature of injury
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Field supervisor notified
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Describe what actions were taken
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Follow up needed?
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Description of follow up if applicable
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Pictures if applicable
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If incident is something other than injury related complete this section
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Description of incident
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Field supervisor notified?
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Follow up action required?
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Description of follow up action if applicable
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Pictures if applicable
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Was this incident preventable?
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What can be done to prevent this incident from re-occurring?
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Suggested corrective action
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Further follow up required?
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Signatures of all involved parties below
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Signature 1
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Signature 2
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Signature 3
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Signature 4
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Signature 5
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Signature 6
