Information

  • Job Site Name

  • Conducted on

  • Prepared by

  • Location
  • Personnel

SECTION I

  • Name

  • Date and time of incident

  • 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.

  • Photo of injury

  • Foremen-Describe what happened

  • Injured personnel - Describe what happened

  • Witness - Describe what happened

  • Detail any first-aid or medical treatment administered. (Provide names)

DETAILS OF DAMAGE, IF APPLICABLE

  • 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 of foremen

  • Signature of injured

  • Signature of witness

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.