Painters USA Incident/injury Report Checklist

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

  Date

INCIDENT DESCRIPTION

• AUDITOR DESCRIBE HOW THE INCIDENT OCCURRED

• AUDITOR SIGNATURE

  Sign

• INJURIED/NEAR MISS EMPLOYEE DESCRIPTION

• EMPLOYEE SIGNATURE

  Sign

• WHERE THERE ANY WITNESSES? IF SO LIST THEIR NAMES

• WITNESS DESCRIPTION OF WHAT HAPPENED

• WITNESS SIGNATURE

  Sign

• WITNESS #2 DESCRIPTION OF WHAT HAPPENED

• WITNESS #2 SIGNATURE

  Sign

• 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.....

  Media

• 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

  Media

• DETAILS OF MEDICAL OR FIRST AID TREATMENT

DETAILS OF DAMAGE

• DESCRIBE DAMAGE

• PHOTOS OF DAMAGE

  Media

• 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?

  Yes

  No

  N/A

• HAS THE SAFETY MANAGER BEEN NOTIFIED?

  Yes

  No

  N/A

• HAS THE HR MANAGER BEEN NOTIFIED?

  Yes

  No

  N/A

• FOREMAN SIGNATURE

  Sign

FIELD SUPERVISORS

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

  Yes

  No

  N/A

• FIELD SUPERVISOR SIGNATUE

  Sign