Injury Accident And Incident Reports

Updated: over a week ago

Injury, Accident and Incident Reports

General

2. Please specify the date and time of the incident:


Photo Comment

3. Please specify the date and time the incident was reported:


Photo Comment

4. Who was the incident reported to?


Photo Comment

5. Please specify the exact location of incident:


Photo Comment

6. Were there any witnesses?


Photo Comment

7. Provide names of witnesses:


Photo Comment
Injury Details

1. Please describe the injuries sustained:


Photo Comment

2. Was any first-aid or medical treatment provided? Write down more details on this in Comments.


Photo Comment
Damage

1. Was there any damage to property?


Photo Comment

2. what is the extent of damage?


Photo Comment

3. Please provide a picture of the damage:




Upload
Photo Comment
Vehicle Damage

1. Please provide a picture of the damage to the vehicle:




Upload
Photo Comment

2. Vehicle ID


Photo Comment

3. Please provide a detailed description of the incident – include ambient conditions, distractions, or any other note-worthy points


Photo Comment

4. Please provide a picture of the environment after the incident.




Upload
Photo Comment

5. What directly caused the incident?


Photo Comment

6. Please provide a photo of this cause.




Upload
Photo Comment
Analysis

1. What were the contributing factors that caused the incident?


Photo Comment

2. Please provide a picture of the contributing factors:




Upload
Photo Comment

3. Please suggest corrective actions to be taken:


Photo Comment

4. Please assign a person to ensure corrective actions are acted upon:


Photo Comment

5. Could the incident have been severe than it was?


Photo Comment

6. Is there a possibility for reoccurrence of such incidents?


Photo Comment

Is this sample what you are looking for?
Sign up to use & customise this template, or create your own custom checklist:

Checklist by GoAudits.com – Please note that this checklist is intended as an example. We do not guarantee compliance with the laws applicable to your territory or industry. You should seek professional advice to determine how this checklist should be adapted to your workplace or jurisdiction.

goaudits app

Get started on a free trial

Seeing is believing! Try the full platform FREE for 14 days with your own data.
Or ask us to setup the system for you, at no cost.