Maalt Transport

• Audit Title

• Document No.

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

GENERAL INFORMATION

• Name of Employee

• Date and time incident was reported.

  Date

• Date and time of incident

  Date

• Vehicle and Trailer

• To whom was the incident reported?

• Location of incident. (Specify site location)

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

  Yes

  No

  N/A

DETAILS OF INJURY, IF APPLICABLE

• We're there any injuries, if so describe the nature of injuries

  Yes

  No

  N/A

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

  Yes

  No

  N/A

• Was Axiom Medical Management notified?

  Yes

  No

  N/A

• Has the employee been sent for a Drug & Alcohol test to include time taken to facility? (Drug test must be completed within 24 hrs. / Alcohol must be done within 8 hrs.)

  Yes

  No

  N/A

DETAILS OF DAMAGE, IF APPLICABLE

• Property Damage

  Minor

  Serious

  Major

• Asset Damage

  Vehicle

  Trailer

  N/A

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

• Employee Statement (In their own words)

• Witness 1 Statement and Name (In their own words)

• Witness 2 Statement and Name (In their own words)

• Witness 3 Statement and Name (In their own words)

• Immediate (Direct Causes):

ANALYSIS

• Was there any underlying contributing factors? I.e. Fatigue, Hours of Service, Distracted Driving, Weather, Family Issues etc.

  Yes

  No

  N/A

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

• What is the possibility of reoccurring

  High

  Medium

  Low

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• Signature

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