Title Page
-
Site conducted
-
Document No.
-
Brief description of incident
-
Client
-
Site
-
Vendor
-
Subcontractor(s)
Incident type
-
Incident type
-
Is this an LTI?<br>(was a person injured and unable to return to work the same day?)
-
How many days was the injured person off work?
Details of time & people involved
-
Name of injured person / loss
-
Position
-
Contact no
-
Incident location / job
-
Incident address
-
Date / time of incident
-
Notifying person
-
Plant involved in incident
Details of injury
-
Was a person injured?
-
Injury location
- Ankle
- Arm
- Back
- Chest
- Ear
- Eye
- Feet
- Fingers
- Hands
- Head
- Hips
- Knees
- Legs
- Neck
- Nose
- Shoulder
- Skin
- Stomach
- Teeth
- Thumb
- Toes
- Wrist
- Multiple
- Other
-
Injury type
- Amputation
- Bruise
- Burns / Scalds
- Cold Stress
- Concussion
- Cut / Laceration
- Deafness
- Dermatitis
- Dislocation
- Fracture
- Fume Inhalation
- Heat Stress
- Infection / Disease
- Inflammation
- Internal Injury
- Poisoning / Toxic Effects
- Psychological Stress
- Puncture
- Skin Irritation
- Sprain
- Strain
- Other
-
Photos of injury
Incident details
-
Photos of incident site
-
What was the task being performed?
-
What happened (actual)?
-
What could have happened (potential)?
-
Witnesses
Witness
-
Name
-
Company
-
Contact no
-
Was work ceased?
-
Date/time work ceased
Details of treatment or action taken
-
Action taken
-
Was first aid given?
-
Personal administering first aid
-
Injured person referred to
Corrective action
-
What can be done to prevent recurrence?
-
Is more investigation required (i.e. more than a minor injury)
-
Please use form V-F-02
