SAFETY & RISK
Safety Incident Report Form
Checklist Items
1
Date and time of incident recorded accurately
Pass/Fail
Required
2
Location of incident clearly documented
Pass/Fail
Required
3
Type of incident
Multiple Choice
Required
- Personal Injury
- Near Miss
- Property Damage
- Environmental Release
- Fire/Explosion
4
Number of people involved
Numeric
Required
Min: 1 persons
5
All injured parties identified and documented
Pass/Fail
Required
6
Severity level of incident
Multiple Choice
Required
- Minor (First Aid Only)
- Moderate (Medical Treatment)
- Serious (Lost Time)
- Critical (Hospitalization)
- Fatality
7
Immediate medical attention provided if required
Pass/Fail
Required
8
Area secured and made safe
Pass/Fail
Required
9
Witnesses identified and contact information collected
Pass/Fail
Required
10
Root cause analysis completed
Pass/Fail
Required
11
Contributing factors documented
Pass/Fail
Required
12
Corrective actions identified and assigned
Pass/Fail
Required
13
Management and safety department notified
Pass/Fail
Required
14
Regulatory authorities notified if required
Pass/Fail
Required
15
Report reviewed and approved by supervisor
Signature
Required
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