Client / Site

Conducted on

Prepared by



**** Describe what Occured ****

Names and no. employees; any witnesses; any plant or equipment used; time of the day or night; any other factors?

**** What could be done to prevent a repeat? ****

Please Explain?

Date Operations Team was notified?
Date Operations Team conducted risk assessment?

Monthly SHEC Meeting where findings were discussed?

Select date
Venue Manager
Area Manager
Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.