L. Keeley Incident Report - Local

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

INCIDENT INFORMATION

• Incident Number

Incident Type

• Auto Accident

• Injury/Illness

Security Breach

• Security Breach

Security breach type

• Unauthorized entry on Job Site

• Unauthorized access into lay down/dumpster area

• Unauthorized entry into Store

• Unauthorized use of store equipment

• Company

• Name

• Other

Asset Damage / Loss

• Assets Damage/Loss

Asset Type

• Building

• Store Merchandise

• Store Equipment

• Store Cases/Display etc.

• Vehicle

• Office Computer Equipment

• Rental Equipment

• Furniture

• Tools

• Add media

  Media

• Item Description

• Asset ID number

• Make

• Model number

• Serial number

• Year

• Estimated repair/replacement cost

• Damage/loss description

• Responsible Company

• Employee Name

• Badge ID Number

Formal Complaint

• Formal Complaint

• Name of complainant

• Contact telephone number

• Address

Type of complaint

• Dust

• Water

• Lighting

• Noise

• Odor

• Visual

• Safety

• Other

Nature of complaint

• Description

• Change in landscape aesthetics

• Language

• Land use limitations - barriers, transportation, land values, sustainability

• Affects on customer

• Safety Issue

• Other

Non-Compliance / Process

• Non-Compliance / Process

Requirement Type

• Legal Requirement

• Client Requirement

• L. Keeley Requirement

• Other

Non-compliance / procedure failure type

• Badging

• Quality

• Safety

• Other

• Non-compliance Description

• Regulatory Authority

• Source Of Obligation

Fire

• Fire

Fuel type

• Vegetation

• Wood

• Fuel - diesel

• Fuel - petrol

• Propane

• Paper

• Paint

• Other

• Description

Source of fire

• Electrical

• Lightning

• Cutting/welding

• Hot surface

• Static electricity

• Auto ignition

• Instrumentation

• Flame

• Friction

• Explosives

• Location of fire

Method of extinction

• Extinguisher

• Blanket

• Water

• Other

• Details

• Add media

  Media

Haz-Mat/SWPPP

• Haz-Mat/SWPPP

• General Description

• Add media

  Media

• Surface Water

• Contamination

• Depletion of water source

• Change in chemistry or properties

• Temperature change

• Groundwater

• Contamination

• Depletion of water source

• Change in chemistry or properties

• Temperature change

• Change in pressure

• Soil

• Contamination

• Compaction

• Erosion

• Air

• Contamination

• Other

• Description

Source of impact

• Emission of dust / particles

• Spills of liquids

• Emission of gas

• Seepage of liquid

• Clearing / excavation

• Subsidence

• Bulbs

• Ballast

• Mercury

• Uncontrolled access / egress

• Collision

• Emission of light / noise

• Winds

• Rain

• Other

Contaminant

• Contaminant

• Volume released

• Volume recovered

Area

• Area / distance covered

• Description

• Duration of incident

• Estimated duration of impact

Actual Environmental Classification

• Irreparable / long term

• Major remedial action

• Localized serious remedial action

• Localized min remedial action

• Little if any action

• Add signature

  Sign

Description

Incident Details

• Incident Date/Time

  Date

• Reported Date/Time

  Date

• Location

• Reported by:

• Reported to:

• Supervisor Responsible

Personnel Involved

Person

• Name

• Employee ID

• Relationship to incident (e.g. Witness, Operator, Injured Person, Complainant)

• Injured?

• Head and Neck

• Cranium

• Ear

• Eye

• Face

• Mouth

• Neck

• Nose

• Upper limbs

• Elbow

• Lower arm

• Upper arm

• Shoulder

• Wrist

• Hand

• Fingers

• Trunk

• Abdomen

• Lower back

• Upper back

• Chest

• Pelvis

• Groin

• Genitals

• Lower limbs

• Ankle

• Lower leg

• Upper leg

• Hip

• Knee

• Foot

• Toe

• General

• Circulatory system

• Digestive system

• Nervous system

• Respiratory system

Nature of injury

• Burns / Scals

• Concussion with intracranial injuries

• Contusions with intact skin surfaces

• Dermatitis

• Dislocation

• Effects of radiation

• Effects of toxic substances

• Electric shock

• Fracture

• Heart and vascular disease

• Infectious and parasitic disease

• Internal injuries

• Open wound

• Sprains and strains

• Thermal stress

• Superficial injuries

• Inflammation

• Other

Source of Energy

• Internal energy

• Fall

• Stepping on, sitting on

• Rubbing or abrading

• Grasping or touching

• Striking against

• Muscle effort

• Other

• External energy

• Asphyxiating substance

• Electrical energy

• Mechanical

• Radiation

• Toxic substance

• Attacks

• Falling objects

• Microbiological exposure

• Sound / vibration

• Corrosive substance

• Flying objects

• Thermal / heat

• Other

• Contaminant

Treatment Details

• Treated by:

• Treatment given:

• Treatment date

  Date

Classification

• Lost Time Injury (LTI)

• Disabling Injury (DI)

• Medical Treatment Injury (MTI)

• First Aid Injury (FAI)

Corrective Actions

Actions

• Action title

• Action Description

• Assigned to

• Date assigned

  Date

• Due date

  Date

• Priority 1 = Low 3 = High