Key Document 7: Accident, Incident Report

• Incident and/or Accident Reporting

• Conducted on

  Date
• Location
  Address

General Details

• Name

• Date and time of incident

  Date

• Location of incident. (Specify site location)

• Was there any witness(es)? If yes, provide name(s).

  Yes

  No

  N/A

• Name the Specific Area the incident/Accident Happened.

DETAILS OF INJURY, IF APPLICABLE

• Describe injury.

• Detail any first-aid or medical treatment administered. (Provide names)

DETAILS OF DAMAGE, IF APPLICABLE

• Property Damage:

  N/a

  Vehicle

  Equipment

  Private Property

• Photo of damage.

  Media

• Vehicle ID:

• Detailed description of incident. (Include environmental conditions at time of incident)

• Immediate (Direct Causes): Slips, Trips and Fall.

• Direct cause photo:

  Media

• Facilities Maintenance:

  Yes

  No

  N/A

ANALYSIS

• Contributing factors photo if applicable:

  Media

• Corrective Action (Include detail description of action and person(s) responsible for actions)

• What was the potential for severity?

  Minor

  Serious

  Major

• What could have potentially happened?

• What is the probability of reoccurrance?

  Remote

  Improbable

  Probable

• Signature

  Sign