Information

  • Audit Title

  • This is the subject of the incident

  • 1.) Date of Incident

  • 2.) Name of Knife River employee(s) involved

  • Employee
  • Name

  • 3.) Brief Description of Incident by Supervisor

  • Picture of injury and/or damage.

  • Sketch of incident.

  • Rate the seriousness of this incident, 0 = Informational only, 10 = fatality

  • 4.) Location of Incident
  • 5.) Was any Knife River equipment involved?

  • Equipment
  • Make/Model

  • Equipment Number

  • Describe equipment damage

  • Add media

  • 6.) Were any Non Knife River individuals injured?

  • Involved Person
  • Name

  • 7.) Were there any injuries?

  • If the above answer was Yes, then:

  • Injured person
  • Name

  • Describe injury

  • Was first aid administered?

  • If above answer was yes, describe first aid given:

  • Name of person administering first aid:

  • Did injured person see a doctor?

  • If yes, then:

  • Name of doctor, clinic or emergency room

10.) Employee Incident Statement (to be completed by involved employee(s))

  • Employee Statements:

  • Statement
  • Name

  • Add drawing

11.) Actions Taken

  • Corrective and/or disciplinary actions

  • Suggestions to avoid incident from reoccurring

12.) If applicable, supplementary or follow-up incident statements must be completed by:

  • Another Knife River supervisor

  • Name

  • Statement

  • Witness

  • Name

  • Statement

SIGNATURES OF INVOLVED EMPLOYEES:

  • 13.) Knife River supervisor completing form:

  • 14.) Knife River employee(s) involved

  • Employee
  • Name

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.