Template Information
Work place incident details
Category: general
Template Questions
- Name
- SECTION I
- Date and time incident was reported. Date
- Date and time of incident Date
- To whom was the incident reported?
- Location of incident. (Specify site location)
- Applicable "Safety First" Rules:
- Describe injury.
- Detail any first-aid or medical treatment administered. (Provide names)
- Property Damage:
- Photo of damage.
- Vehicle No:
- Detailed description of incident. (Include environmental conditions at time of incident)
- Environmental photo:
- Immediate (Direct Causes):
- Direct cause photo:
- Contributing (underlying) Factors:
- Contributing factors photo:
- Corrective Action (Include detail description of action and person(s) responsible for actions)
- ANALYSIS
- What could have potentially happened?
- Sign-off Date/ Time Date
- Signature