Information

  • Document No.

  • Audit Title

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Personnel

Site details

  • Building location employee was working at;

  • Location within building.

Accident/Incident Details

  • Date and time of injury;

  • Employee Name

  • Job Title:

  • Location of accident (please be specific)

  • Location of accident (please be specific)

  • Nature of Incident or Injury

  • Describe who, what, when,where, why and how injury occurred:

  • Contributing causes of the Incident: (Inadequate training, Inadequate supervision. Employee not following proper safety procedures and instructions)

  • Possible Cause or Causes of the incident: (Inadequate PPE, Not Paying attention to surroundings, failure to utilise safety equipment)

  • What is the employee's current status if injured: Describe. ( Returned to work the next day, off of work do to injury, off of work do to restrictions, In hospital, etc.)

  • Severity:

  • Lost time?

  • OSHA Recordable?

Supervision details

  • Was a Risk Assessment completed before work began:

  • HSE Informed?

Injured Party statement

  • Name & Signature of the injured party

Witness statements

  • Witnesses 1

  • Name and signature of the witness 1

  • Witnesses 2

  • Name and signature of the witness 2

  • Witnesses 3

  • Name and signature of the witness 3

Injury Details if Applicable

  • What type of provider performed treatment?

  • Part of Body injured:

  • Will the employee have any restrictions:

  • If so, what are they?

  • Anyone else injured:

Corrective Actions

Root Cause of Accident

What is the root cause of the accident?

Action: Short Term

  • What was the immediate action taken to correct the issue (how was this done):

  • Who was the responsible party for correcting the issue:

Action: Long Term

  • What is the long term action needed to correct the issue:

  • Who was the responsible party for correcting the issue:

Investigation Conclusions

Person Completing Form (please sign below)

  • Is the above report a true reflection of the Accident / Incident

Supervisor in Charge (please sign below)

  • Is the above report a true reflection of the Accident / Incident

Injured Party witnessing the completion of the forms agreement with the content and that it is a true reflection of the accident / Incident

  • Is the above report a true reflection of the Accident / Incident

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.