Audit
Willows Pool Shop
Completed by:
Job Title:
Phone Number
Mailing Address
Full Name
Job Title
Home Address
Birthdate
Gender
Name of attending Physician or Health Care Professional
Location where treatment was given
Facility Name
Street Address
Was Employee Treated in Emergency Room
Was employee hospitalized overnight as an in-patient?
If yes, length of stay
Case #
Choose one:
Note: If a fatality occurred or more than 3 employees were hospitalized, OSHA must be verbally notified within 8 hours.
Did incident occur on employer's premises?
If yes, where on premises did the incident occur?
If no, location of incident?
What was the employee doing just before the incident occurred? (Be as specific as possible. If the employee was using tools, equipment, or materials, name them and specify what the employee was doing with them). Example: "climbing a ladder while carrying painting materials", "daily computer entry"
Explain how the incident occurred. List the events that resulted in the injury or illness, what happened, how it happened, and name objects and how they were involved.
Describe the injury/illness. Indicate the part of the body that was affected and h ow it was affected.
Name the object or substance that directly injured the employee. Example: concrete floor
Name, phone, address
Name, phone, address
Has the family been contacted?
Has the personnel department been contacted?
Has the State Workers Compensation Agency been contacted?
Has the companies Workers' Compensation carrier been contacted?
Has the cause of the injury/illness been corrected?
Describe future action to be taken, including preventative measures to ensure that such injury/illness does not occur again.
Company:
Accident Report Number
Employee:
Telephone Number
Department
Supervisor
Accident Location
The the employee involved in the accident - Briefly explain in your own words the circumstances that led to the accident event. Also include your involvement in the accident. Your comments are important to help determine the causes of the accident and correct any unsafe conditions. Thank you.
I have written the above statement and certify that it is true to the best of my knowledge.
