Information
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Document No.
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Audit Title
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Client / Site
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Conducted on
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Prepared by
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Location
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Personnel
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PLACE / area incident occurred
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TIME AND DATE OF OCCURRENCE
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PERSONS INVOLVED
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ARE THERE WITNESSES
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WITNESS NAME AND CONTACT DETAILS
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WHAT LED UP TO INCIDENT (give specific details of actions, products in use ect)
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WHAT HAPPENED DURING INCIDENT (attach photos or sketch if necessary)
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WHAT OCCURRED AFTER THE INCIDENT ( include staff, persons reaction)
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ACTION TAKEN OR SUGGESTED TO PREVENT SIMILAR INCIDENT
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PERSON OR PERSONS INJURED
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DATE OF BIRTH
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CONTACT DETAILS / ADDRESS AND PHONE NUMBER
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INJURIES REPORTED ( full details, including parts of body affected )
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TREATMENT ( include who gave first aid, hospital / doctors name and any follow up treatment )
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DATE AND TIME
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POSTION
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SIGNATURE
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ACTION TAKEN
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DATE AND TIME
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BY WHOM
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ACTION
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REVIEW
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1. ACCIDENT REPORT FILED IN REGISTER AND COMMITTEE NOTIFIED
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WORK COVER NOTIFIED
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HAZARD ELIMINATED AND OR CONTROLLED BY
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ACCIDENT REPORT ACTIONS AND SOLUTIONS SIGNED OFF
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SIGNATURE CHAIRPERSON
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DATE
