Incident Report Checklist
Retail
Work Place Incident Details
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Audit

SECTION I

Date and time of incident
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Date and time incident was reported.
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To whom was the incident reported?
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Location of incident. (Specify site location)
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Supervisor's Name
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Supervisor's Phone Number
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Was there any witness(es)? If yes, provide name(s).
Yes
No
N/A
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PERSON(S) INVOLOVED

Name (Person 1):
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Phone:
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Sex:
Male
Female
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Age;
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Job Title:
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Time on job: (Yrs & Mos)
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Job Status:
Full-time
Part-time
Temporary
Seasonal
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Classification:
Search and select all that apply
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Employee Disposition Status:
Returned to Work
Modified Duties
Sent Home
To Doctor
To Hospital
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Medication prescribed? If yes list medications.
Yes
No
N/A
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NATURE OF INJURY

Describe injury.
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Detail any first-aid or medical treatment administered. (Provide names)
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Property Damage:
None
Minor
Serious
Major
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Photo of damage.
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Property Damage:
N/a
Vehicle
Equipment
Private Property
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Photo of damage.
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Estimated cost of damage:
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Vehicle ID:
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Make/Model:
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Age:
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Equipment ID:
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Model:
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Age:
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Detailed description of incident. (Include environmental conditions at time of incident)
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Environmental photo:
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Environmental photo:
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Immediate (Direct Causes):
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Direct cause photo:
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Direct cause photo:
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Contributing (underlying) Factors:
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Contributing factors photo:
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Corrective Action (Include detail description of action and person(s) responsible for actions)
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What was the potential for severity?
Minor
Serious
Major
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What could have potentially happened?
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What is the probability of reoccurrance?
Remote
Improbable
Probable
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