o team incident form

• Audit Title

• Document No.

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

1.0 Was proper people notified

• 1.01 Plant management

  Yes

  No

  N/A

• 1.02 Plant safety department

  Yes

  No

  N/A

• 1.03 Plant operations

  Yes

  No

  N/A

• 1.04 Plant maintenance

  Yes

  No

  N/A

• 1.05 Contractor representative

  Yes

  No

  N/A

• 1.06 Plant environmental

  Yes

  No

  N/A

• 1.07 Plant chemist

  Yes

  No

  N/A

• Correct outside agencies

  Yes

  No

  N/A

Work activity during event

• Describe work activity

• Photos of scene

  Media

Type of event

• What type of event

  Incident/accident

  near miss

  hazard recognition

  success

• Time and date of occurrence

  Date

Additional information

• List employees involved

• Name of supervisor

• Start of shift time

  Date

• Exact location of incident

• Photos of incident scene

  Media

Description

• Employee's description

• Immediate action taken

• Supervisor description

• Supervisors immediate action

• Other important information (what hospital, tools used,weather condition type of information)

• Who was contacted

• Lead employee verify correct description

  Sign

• Person submitting report

  Sign

• Date and time report submitted

  Date