Audit

Site details
Location of Incident

Site that employee was working at;

Accident/Incident Details
Date and time of injury;

Employee Name

Job Title:

Nature of Incident or Injury

Describe who, what, when,where, why and how injury occurred:

Contributing causes of the Incident: (Inadequate training, Inadequate supervision. Employee not following proper safety procedures and instructions)

Possible Cause or Causes of the incident: (Inadequate PPE, Not Paying attention to surroundings, failure to utilise safety equipment)

What is the employee's current status if injured: Describe. ( Returned to work the next day, off of work do to injury, off of work do to restrictions, In hospital, etc.)

Supervision details

Was Risk Assessment completed before work began:

Facility Safety Office Informed?

Date and Time when the employer was notified:
Injured Party statement

Name & Signature of the injured party
Witness statements

Witnesses 1

Name and signature of the witness 1

Witnesses 2

Name and signature of the witness 2

Witnesses 3

Name and signature of the witness 3
Injury Details if Applicable

Where was the Medical treatment first provided?

Provider Doctor Details

Part of Body injured:

Image of injury

Will the employee have any restrictions:

Action: Short Term

What was the immediate action taken to correct the issue (how was this done):

Action: Long Term

What is the long term action needed to correct the issue:

Additional Information

Lessons Learned:

Please provide all attachments that apply: Pictures, Drawings, Training Records, Statement of Employee, Statement of Witness/es, Other.

Person Completing Form (please sign below)
Is the above report a true reflection of the Accident / Incident
Supervisor in Charge (please sign below)
Is the above report a true reflection of the Accident / Incident
Injured Party witnessing the completion of the forms agreement with the content and that it is a true reflection of the accident / Incident
Is the above report a true reflection of the Accident / Incident
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.