Audit

SECTION I
Date and time of incident
Date and time incident was reported.

To whom was the incident reported?

Location of incident. (Specify site location)

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

PERSON(S) INVOLOVED

Name (Person 1):

Age;

Job Title:

Time on job: (Yrs & Mos)

Medication prescribed? If yes list medications.

NATURE OF INJURY

Detailed deskription of Incident

Supporting Photo

Describe injury. (If applicable)

Detail any first-aid or medical treatment administered. (Provide names)

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

What was the potential for severity?

What could have potentially happened?

What is the probability of reoccurrance?

Select date
Signature
Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.