Information
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Audit Title
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This is the subject of the incident
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1.) Date of Incident
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2.) Name of Knife River employee(s) involved
Employee
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Name
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3.) Brief Description of Incident by Supervisor
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Picture of injury and/or damage.
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Sketch of incident.
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4.) Location of Incident
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5.) Was any Knife River equipment involved?
Equipment
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Make/Model
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Equipment Number
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Describe equipment damage
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Add media
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6.) Were any Non Knife River individuals injured?
Involved Person
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Name
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7.) Were there any injuries?
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If the above answer was Yes, then:
Injured person
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Name
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Describe injury
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Was first aid administered?
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If above answer was yes, describe first aid given:
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Name of person administering first aid:
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Did injured person see a doctor?
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If yes, then:
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Name of doctor, clinic or emergency room
10.) Employee Incident Statement (to be completed by involved employee(s))
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Employee Statements:
Statement
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Name
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Add drawing
11.) Actions Taken
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Corrective and/or disciplinary actions
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Suggestions to avoid incident from reoccurring
12.) If applicable, supplementary or follow-up incident statements must be completed by:
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Another Knife River supervisor
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Name
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Statement
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Witness
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Name
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Statement
SIGNATURES OF INVOLVED EMPLOYEES:
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13.) Knife River supervisor completing form:
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14.) Knife River employee(s) involved
Employee
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Name
