Information
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Project ID & Employee Name
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Audit Title
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Client / Site
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Conducted on
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Prepared by
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Location
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Address
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Personnel
Employee Information
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Employee Name:
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Address:
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Street:
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City:
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State:
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ZIP Code:
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Social Security Number:
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Date Of Birth:
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Contact Number:
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Marital Status:
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Number of Dependents Under 18:
- 0
- 1
- 2
- 3
- 4
- 5
- 6
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Date of Hire:
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Wages:
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Employee Occupation:
- Project Manager
- Engineer
- Superintendent
- Foreman
- Operating Engineer
- Piledriver
- Carpenter
- Laborer
- Other
Accident Information
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Incident Date:
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Incident Time:
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Date Reported To Employer:
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Activity Engaged In:
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Accident Description:
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Please attach photos as necessary
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Is there a reason to doubt the validity of the claim? (If yes, please explain):
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Was employee performing regular duties?
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Did the incident occur on premises? (If no, provide location)
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Street:
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City:
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State:
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ZIP Code:
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County:
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Did another person cause the accident? (If yes, name of person)
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Please attach photos as necessary
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Are there any witnesses? (If yes, name of witness)
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Was there a police report filed?
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Name of Police Department:
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Report Number:
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Phone Number:
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Was Cal-OSHA notified of the incident?
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District Office Location:
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Street:
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City:
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State:
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County:
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Office Phone Number:
Injury Information
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Part of the body injured:
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Nature of injury:
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Cause of injury:
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Attach photos as necessary
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First Aid Only?
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Recordable?
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Is employee losing time? (If so, date began)
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Date of lost time:
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Number of lost days:
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Employee return to work? (If so, date returned to work)
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Date returned to work:
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Employee paid for date of accident?
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Was safety apparatus provide?
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Was safety apparatus used?
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Safety apparatus description:
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Attach photos as necessary
Provider Information
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Medical treatment rendered?
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Under active medical care?
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Medical Provider Name:
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Phone Number:
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Street:
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City:
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State:
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ZIP Code:
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Additional Comments:
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Attach photos as necessary
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Report Conducted By:
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