Incident Report

1. Document Number

2. Audit Title

3. Client, Site, or Project

1. Date and Time of Report

2. Prepared By

3. Location

1. Date and Time of Incident

2. Location of Incident

3. Incident Priority Level

4. Site or Project Name

1. Type of Incident

2. If Other, please describe the type of incident

3. Name of On-Duty Supervisor at Time of Incident

1. Is immediate medical attention required?

2. If Yes, what kind of medical attention was administered?

1. Describe What Happened

2. Weather or Environmental Conditions at Time of Incident

3. If Other, please describe the weather conditions

1. Which evidence needs to be attached to this report?

2. Evidence Description

3. Evidence ID Number (if applicable)

1. Vehicle Make

2. Vehicle Model

3. Vehicle Registration

4. Driver (if applicable)

1. Damage Description

2. Damage ID Number (if applicable)

1. Full Name of Person Involved

2. ID Number

3. Contact Phone Number

4. Relation to the Incident

5. Please describe this person's involvement with the incident

1. Does this person wish to make a preliminary statement?

2. Statement Regarding Incident

1. Has this person sustained an injury?

2. Type of Injury or Illness

3. Parts of Body Affected

4. Describe this injury or illness

1. Are corrective actions required?

2. Have all required corrective actions been added?

3. Please add any corrective actions to the appropriate questions above

1. Name of Person to Follow Up

2. Name & Signature of Reporter