Information
-
Audit Title
-
Document No.
-
Client / Site
-
Conducted on
-
Prepared by
-
Location
-
Personnel
SECTION I
-
Name
-
EMCOR Company:
-
Date and time of incident
-
Weather Conditions:
-
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).
DETAILS OF INJURY, IF APPLICABLE
-
Describe injury.
-
Detail any first-aid or medical treatment administered. (Provide names)
DETAILS OF DAMAGE, IF APPLICABLE - DO NOT TAKE PHOTOS OF INJURED PEOPLE
-
Property Damage:
-
Photo of damage.
-
Property Damage:
-
Photo of damage.
-
Vehicle ID:
-
Detailed description of incident. (Include environmental conditions at time of incident)
-
Environmental photo:
-
Immediate (Direct Causes):
-
Direct cause photo:
-
Direct cause photo:
ANALYSIS
-
Contributing (underlying) Factors:
-
Contributing factors photo:
-
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
