Incident Details

  • INJURY (MEDICAL FACILITY TREATMENT REQUIRED)

  • MINOR INJURY - BASIC FIRST AID (NO MEDICAL FACILITY TREATMENT NEEDED)

  • ACCIDENT

  • NEAR MISS INCIDENT

  • PROPERTY DAMAGE

  • LOCATION OF INCIDENT

  • ENTER DATE AND TIME

INCIDENT DESCRIPTION

  • AUDITOR DESCRIBE HOW THE INCIDENT OCCURRED

  • AUDITOR SIGNATURE

  • INJURIED/NEAR MISS EMPLOYEE DESCRIPTION

  • EMPLOYEE SIGNATURE

  • WHERE THERE ANY WITNESSES? IF SO LIST THEIR NAMES

  • WITNESS DESCRIPTION OF WHAT HAPPENED

  • WITNESS SIGNATURE

  • WITNESS #2 DESCRIPTION OF WHAT HAPPENED

  • WITNESS #2 SIGNATURE

  • WAS THE EMPLOYEE WEARING THE REQUIRED SAFETY GEAR AND FOLLOWING COMPANY SAFETY POLICIES?

  • WHAT WAS THE NATURE OF THE INCIDENT?(i.e. fall, struck by, slip,trip,)

  • ADD PICTURES OF THE AREA, EQUIPMENT ETC.....

  • HOW/WHY DID THIS HAPPEN?

  • WHAT CAN BE DONE TO PREVENT RE-OCCURRENCE?

DETAILS OF INJURY

  • DESCRIBE THE INJURY

  • ADD PHOTOS OF INJURY IF POSSIBLE

  • DETAILS OF MEDICAL OR FIRST AID TREATMENT

DETAILS OF DAMAGE

  • DESCRIBE DAMAGE

  • PHOTOS OF DAMAGE

  • DESCRIPTION OF WHAT HAPPENED

ACTION STEPS TO PREVENT FUTURE OCCURRENCE

  • WHAT CORRECTIVE MEASURES NEED TO BE TAKEN TO PREVENT FUTURE OCCURRENCE? (TRAINING,EQUIPMENT, PRE-PLANNING)

FOREMAN REPORTING

  • HAS YOUR FIELD SUPERVISOR BEEN NOTIFIED?

  • HAS THE SAFETY MANAGER BEEN NOTIFIED?

  • HAS THE HR MANAGER BEEN NOTIFIED?

  • FOREMAN SIGNATURE

FIELD SUPERVISORS

  • HAS THE HR, SAFETY MANAGER AND MANAGEMENT TEAM BEEN NOTIFIED?

  • FIELD SUPERVISOR SIGNATUE

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