Information
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Audit Title
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Document No.
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Client / Site
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Conducted on
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Prepared by
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Location
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Personnel
General information
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Select date
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Customer
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Incident location
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Job Number
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Superintendent
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County
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State
Employee Information
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Employee Name
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Employee iD Number
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Employee Social Security Number
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Employees Date of Birth
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Employees date of hire
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Employees position
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Employees phone number
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Employees address
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Employees picture
Work Information
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Work Shift
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What time did the shift begin
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Was worked stopped?
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Was this an OQS covered task?
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Was there an injury? If an injury occurred describe it here.
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if there was an injury was medical treatment provided? If medical treatment was provided where was the injured taken?
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Was this an OSHA Recordable?
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Incident Class
- Recordable, Medical Only
- Recordable -Restricted
- Recordable - LTI
- First Aid Only
- Near Miss
- incident
Details of the Incident
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Was a One Call made? One Call Verification Number:
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Is the one call current? (Within 14 Days?)
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Was the line hand spotted? If not hand spotted, why not? (example: unknown line; no detector tape; told not to by operator ect.....
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Was a line finder used to detect lines? If no why not?
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Was the Operator within 18 inches of the pipeline being dug out? If yes to previous question....why?
Drawing
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Make a sketch of the incident
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Pictures of the Incident.
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Add media
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Add media
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Add media
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Add media
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Add media
Details of the incident
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Describe in detail who, what, when and how the incident occurred.
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Sign Your Name
