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Injury, Accident, and Incident Report Checklist Template

Work Place Incident Details
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Audit
SECTION I
Name
Date and time of the incident
Date and time the incident was reported.
To whom was this incident reported?
Location of the incident. (Specific location)
Were there witnesses? List names:
DETAILS OF INJURY, IF APPLICABLE
Describe the injury.
Detail all first-aid or medical treatment administered. (Provide names)
DETAILS OF DAMAGE, IF APPLICABLE
Damage of Property:
Photo of damage.
Damage of Property:
Photo of damage.
Car ID:
Specified description of incident. (Mention environmental conditions at time of incident)
Environmental photo:
Immediate (Direct Causes):
Direct cause photo:
Direct cause photo:
ANALYSIS
Contributing Factors:
Contributing factors photo proof:
Corrective Measure (Include detail description of action and persons responsible for actions)
What was the potential for a more severe case?
What could have happened?
What is the probability of reoccurrance?
Select date
Signature
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Please note that this checklist template is a hypothetical appuses-hero example and provides only standard information. The template does not aim to replace, among other things, workplace, health and safety advice, medical advice, diagnosis or treatment, or any other applicable law. You should seek your professional advice to determine whether the use of such a checklist is appropriate in your workplace or jurisdiction.
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