Foundation
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Audit Title
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Prepared by:
- Mark A. Davis
- Mark D. Davis
- Richard Dickinson
- Anthony Beverly
- Hugh French
- Scott Taylor
- Michael Wright
- James Brown
- Lee Ratliff
- Jason Corbin
- Chuck Ayers
- James Shifflett
- Christopher M. Cole
- Joe Bailey
- Michael Dwyer
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Client / Site
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Conducted on
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Add location
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Add media
Investigation
Investigation Details
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Who will be leading this investigation?
- Mark A. Davis
- Mark D. Davis
- Richard Dickinson
- Anthony Beverly
- Hugh French
- Scott Taylor
- Michael Wright
- James Brown
- Lee Ratliff
- Jason Corbin
- Chuck Ayers
- James Shifflett
- Christopher M. Cole
- Joe Bailey
- Michael Dwyer
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Who will assist in this investigation?
- Mark A. Davis
- Mark D. Davis
- Richard Dickinson
- Anthony Beverly
- Hugh French
- Scott Taylor
- Michael Wright
- James Brown
- Lee Ratliff
- Jason Corbin
- Chuck Ayers
- James Shifflett
- Christopher M. Cole
- Joe Bailey
- Michael Dwyer
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Please enter the date of this investigation.
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Please add the accident/dangerous occurrence reference number this investigation relates too.
Incident Details
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Name of injured person (if any)
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Address
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What kind of incident are you investigating?
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When did the incident occur?
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What type of person was injured? (if any)
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Which part of the body was injured? (if any)
- Head
- Face
- Eyes
- Neck
- Shoulders
- Arms
- Hands
- Fingers
- Chest
- Stomach
- Upper leg
- Lower leg
- Foot
- Toes
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Give details of any tasks being carried out at the time of the incident/injury? (Take photos of the area).
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Have all persons involved in the incident received information, instruction and training for the tasks relating to the incident?
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Describe in detail what happened?
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Describe in detail any injury sustained, if no injury, describe any damaged equipment, plant or machinery etc
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Do you think any persons involved in the incident are negligent in any way, if yes, describe how.
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Please add as many images as you can that relate to the incident.
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List all witnesses of the incident
Medical Treatment
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Was First Aid administered on-site
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Describe what assistance was provided by the First Aider, list any medical equipment used (plasters, bandage, eyewash etc.)
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Obtain signature of First Aider
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Did you require any further treatment?
- Concentra
- Urgent Care
- Patient First
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What was the outcome of this?
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Please provide dates and times
Witness Statement 1
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Please interview all witnesses and ask for signatures
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Name
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Address
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I confirm that the information I have provided in relation to this incident is accurate.
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Select date
Witness Statement 2
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Please interview all witnesses and ask for signatures
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Name
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Address
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I confirm that the information I have provided in relation to this incident is accurate.
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Select date
How did the incident/injury occur?
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Please list the main cause or causes of this incident or injury
- Machine Fault
- Electric Fault
- Not paying attention
- Inexperience
- Floor/Building condition
- Other
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Please list any contributing factor or factors relating to this incident or injury
- Failure to wear PPE
- Inadequate Training
- Improper behaviour
- Poor Housekeeping
- Other
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Describe in detail your findings as to how the incident has occurred?
Corrective and Preventive Action
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What corrective actions have been taken immediately?
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Who carried out the corrective actions?
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Describe what actions can be taken to prevent a recurrence of this incident (Improved training, PPE, improved housekeeping, improved maintenance etc)
Incident Reporting
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Did the injured person require time off work
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Is this a OSHA recordable incident?
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1. Has an injury or illness occurred? (If the answer is yes move to the next question, if no then it is not recordable).
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2. Is the injury/illness work-related? An injury or illness is work-related if an event or exposure in the work environment caused or contributed to the injury or illness, or significantly aggravated a pre-existing condition. (If the answer is yes move to the next question, if no then it is not recorable).
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3. Is the injury or illness a new case? Consider an injury or illness a “new case” if the employee has not previously experienced a recorded injury or illness of the same type that affects the same part of the body, or the employee previously experienced a recorded injury or illness of the same type that affected the same part of body but had recovered completely (all signs and symptoms had disappeared) from the previous injury or illness and an event or exposure in the work environment caused the signs or symptoms to reappear. (If the answer is yes move to the next question, if no then it is not recordable but we must update the previously recorded entry (contact Safety Manager for OSHA 300 log update).
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4. Does the injury or illness meet the general criteria for recordable cases? (If the answer is yes to any part of #4 than it is considered recordable, if no then it is not recordable). - Death - Days away from work - Restricted work activity - Transfer to another job - Medical treatment beyond first aid - Loss of consciousness - Significant injury or illness diagnosed by a PLHCP - A needle stick injury or a cut from a sharp object - Exposure to blood or other bodily fluids - Medical removal under the medical surveillance requirements of an OSHA rule, unless it is voluntary medical removal below the removal levels required by a rule - Work-related Standard Threshold Shift in hearing in one or both ears
Results of Investigation
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Explain the results of your findings, take into account all factors and provide a balanced view, if there is a clear cause for the incident, be sure to list it.
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If any equipment, plant, machinery have been damaged please list and describe the issues
Authorization
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I agree that all information provided by this investigation is accurate.
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Signed by injured person:
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Signed by foreman:
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Signed by superintendent:
