Audit

General

Employer

Site address

Employee or Subcontractor

Date of incident/hazard
Injured Person

Name

Age

Address

Telephone

Accident
Day/Date of incident
Date and time reported

Person who reported Incident

Incident Location

Task being carried out at the time of the incident

Reconstruct sequence of events leading up to incident

Possible cause of incident

Nature of injuries

Estimated time off work

Witnesses statement

Witnesses statement

Witnesses statement

General Incident Description

Briefly describe what happened

Prevention

Briefly describe what action has been taken to prevent a reoccurrence of the incident

Person investigating accident

Signature
Date of report
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.