Information
-
Document No.
-
Audit Title
-
Client / Site
-
Conducted on
-
Prepared by
-
Location
-
Personnel
-
Date/Time
Client Information
-
Company Name
-
Supervisors Name
Employee Information
-
Employee Name
-
Job Title
-
Social Security Number or Employee ID Number
-
D.O.B
-
Male
-
Female
Location Of Accident
-
Address
Record of Reports/Drug Test
-
Employee Report of Accident?
-
Vehicle Inspection Report?
-
Police Report?
-
Drug Test?
-
Alcohol Test?
Witnesses
-
Names and Numbers
Injuries
-
Employee Injured?
-
If yes, please describe injury i.e( location and severity)
-
Other Non Employee Injuries?
-
If yes, please describe injury i.e( location and severity)
Vehicle and/or Equipment Information
-
Make
-
Model
-
Year
-
VIN
-
Insurance and Policy Number
Second Vehicle and/or Equipment Information
-
Model
-
Make
-
Year
-
VIN
-
Insurance and Policy Number
Information of Others Involved
-
Company
-
Name and Number
-
Name And Number
Employee/Driver Statement
-
Signature
-
Date/Time
-
Describe in great detail, how the incident occurred.
Witness Statement
-
Date/Time
-
Name
-
Number you can be reached.
-
Describe in detail, how the incident occurred.
-
Signature
Witness/Third Party Statement
-
Date/Time
-
Name
-
Number you can be reached.
-
Describe in detail, how the incident occurred.
-
Add signature
Investigator
-
Date/Time
-
Accident Summary
-
Photos
-
Skectch or drawing of scene
-
Notes
-
Add signature
