Title Page

  • Conducted on

  • Prepared by

  • Location

Number of Cases

  • Total number of deaths (G)

  • Total number of cases with days away from work (H)

  • Total number of cases with job transfer or restriction (I)

  • Total number of other recordable cases (J)

  • Number of Days

  • Total number of days away from work (K)

  • Total number of days of job transfer or restriction (L)

Injury and Illness Types

  • Total number of Injury

  • Total number of Skin Disorder

  • Total number of Respiratory Condition

  • Total number of Poisoning

  • Total number of Hearing Loss

  • Total number of All Other Illnesses

Establishment Information

  • Your establishment name

  • Address

  • Industry description

  • Standard Industrial Classification (SIC) if known

  • North American Industrial Classification (NAICS) if known

Employment Information

  • Annual average number of employees

  • Total hours worked by all employees last year

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  • Company executive

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.