SITE INCIDENT REPORT

• Audit Title

• Document No.

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

INFORMATION

• SITE NAME

• DATE AND TIME OF INCIDENT

  Date

• DATE AND TIME INCIDENT WAS REPORTED TO SUPERVISOR

  Date

• DATE AND TIME SUPERVISOR ONSITE

  Date
• LOCATION OF INCIDENT
  Address

• EMPLOYEE NAME

• EMPLOYEE JOB TITLE

• SUPERVISOR/MANAGERS NAME

• WITNESS NAMES

• WITNESS CONTACT INFORMATION

INCIDENT INFORMATION

• DESCRIBE TASK BEING PERFORMED WHEN INCIDENT OCCURRED

• DESCRIBE HOW THE INCIDENT OCCURRED

• DESCRIBE ANY DAMAGE/LOSS (IF APPLICABLE)

• DESCRIBE IMMEDIATE ACTIONS TAKEN

• PHOTOGRAPH OF DAMAGE (IF APPLICABLE)

  Media

• HAS THIS EMPLOYEE RECEIVED FULL SITE TRAINING

  Yes

  No

  N/A

• DID EMERGENCY SERVICES ATTEND

  Yes

  No

  N/A

• DETAIL NAME/RANK/NUMBER OF OFFICER(S) ATTENDING

• POST INCIDENT RISK RATING

  Safe

  At Risk

  N/A

• FOLLOW UP ACTIONS

• EMPLOYEE'S SIGNATURE

  Sign

• INVESTIGATING MANAGERS SIGNATURE

  Sign