• Audit Title

  • Document No.

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Personnel

Identification of Incident

  • Date and Time incident took place

  • Date and Time Incident reported

  • Incident Reported By

  • Where exactly did the incident take place

  • Result of accident / action

  • Type of Accident

  • Has this incident resulted in Employees activities being modified or restricted by Dr.

  • Has employee lost time due to the incident? If so? How many days? When is return to work expected?

Incident description

  • Describe in detail, how the incident occurred.

  • Diagram of incident location

  • Relevant evidential photos

  • Was the person or persons involved performing normal job duties at the time of accident?

  • Was the person or persons involved, trained on how to carry out the task

  • Describe what equipment was involved in the accident.

  • Was the equipment being used, suitable for purpose. Has it been checked.

  • If equipment was found to be unsuitable, what faults were identified and describe what action has been taken.

  • Photo of equipment being used during the incident.

Injured Person(s)

  • Name, Address,Date of Birth and Contact details of injured person.

  • In what capacity was the injured person on your premises

  • Describe injuries Sustained as a result of this incident

  • Severity of injuries sustained

Cause of incident

  • What do you believe to be the root cause of the accident?

  • What do you believe to be a contributing factor in the accident?

  • Explain your reasons / evidence to support the causation theory.

Recommendation for additional Control Measures

  • Could this incident have been avoided. Was it foreseeable

  • What are your recommendations to prevent re-occurrence. Describe additional control measures required or relevant action required.

  • Have control measures been implemented

  • How would you now rate the hazard status, following your implemented control measures

Enforcement Authorities & Action

  • Has the incident been reported Medcor and corporate office?

Investigation Summary

  • Investigation Completed by

  • Position

  • Other persons involved in investigation process / Site Manager

  • Position

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.