Phalcon Incident Investigation - local copy

• Audit Title

• Project Name

• Project Address
  Address

• Date/Time of Report

  Date

• Project Number

• Project Foreman

• Prepared by

Incident Information

• Date/Time of Occurrence

  Date

• Incident Type

  Select Injury Illness Fire Automobile Property Damage Near Miss Spill/Leak/Release Other

  • Injury
  • Illness
  • Fire
  • Automobile
  • Property Damage
  • Near Miss
  • Spill/Leak/Release
  • Other

• Name of Injured

• Employer

  JE Richards

  McPhee

  JBL

  Harlan

• Injury Type

  Select Report Only First Aid OHSA Recordable OHSA DART OHSA Lost Time Fatality

  • Report Only
  • First Aid
  • OHSA Recordable
  • OHSA DART
  • OHSA Lost Time
  • Fatality

• Specific Location of Incident

• Where was Treatment Provided?

Witness Information

• Name

• Address

• Employer

• Phone Number

• Email Address

Additional Witness

• Name

• Address

• Employer

• Phone Number

• Email Address

Incident Details

• Incident Description

• Photographs

  Media

• Sketches

  Drawing

• Conclusions/Recommendations

• Immediate Corrective Actions Taken

• Follow Up Actions Required

• Person Responsible for Follow Up

• Date Corrective Actions Completed

  Date

• Signature

  Sign