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Complete the appropriate sections:
Part of Body:
Immediate Action Taking
Supervisor to Complete:
Actual Incident Classification:
1 = Minor
2 = MTI
3 = RWI
4 = LTI
5 = Fatality
An investigation is required for all incidents of 2 or above as well as those with a potential classification of high or extreme, as outlined in SSP-09
Has action been completed?
Close this issue out?
Supervisor to ensure that this information is entered into Sandvik Cintellate incident database and supply feedback of corrective actions to initiator within 14 days.
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.
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