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Injury, Accident, Incident Report Checklist Template

Work Place Incident Details
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Injury, Accident, Incident Report Checklist Template

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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