Time and Date of Incident
Where did this happen?
Details of Affected People
Affected Person
Was the affected person injured in this Incident?
Category of Person
Injury Assessment
Severity Level
Part of Body

Side of Body

Injury Comments

Treatment Details
Was treatment given?
When was treatment given?
Who provided the treatment?

Nature of treatment:

About the Accident/Incident

Where did this occur

Area (if at customers property)

If OTHER, provide details

Give as much detail as you can about: weather or ground conditions, names of substances and equipment involved; circumstances leading up to the event, part played by all people involved and what the injured personas doing at the time of the incident.

What were the sequence of events leading up to this incident taking place?

What was the immediate cause of this incident?

What equipment was being used at the time of the incident?
What PPE was being used at the time?

What Happened

Add any relevant photos
Add sketches (if needed)
What was the Root Cause of this incident?
I understand that the company will use this information to meet its Health and Safety reporting and recording legal duties and for internal management purposes
I agree that the information contained on this form is correct as far as I am aware.
Engineer 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.