ACCIDENT POTENTIAL INDEX REPORT

Project:
Project Code:
       
Description of Potentiality rating: Audit Team:        
1 = Untidy area, minor issues, sets poor example              
2 = Restricted access, unacceptable trash, disorderly            
3 = Rule or procedure violation, potential injury            
4 = Unsafe condition, serious injury potential              
5 = Immediate serious injury potential, stop activity immediately and correct Audit Date & Time:        
        Weather:          
Personnel
  Responsible Violations Leading Indicators
Observed

Comments

Condsunsafe
y Potentialit

unsafe acts
Violations
Description

Contracto
Engineer

Violators
Citizens

Number
Violations

Good

4&5
  x

rs

of
Potentiality

1                        
2                        
3                        
4                        
5                        
5 Totals                      
6 % of Observed People Working Safely                      
7 Number of Violations                      
8 Average Severity of Violations                      
9 Number of Severity 3 Violations                      
  Number of Severity 4 & 5 Violations                      
10 Approximate Number of Workers Observed                    
11 Number of People on Site                  
12 % of Workers Observed                      

Note: Accident Potential Index: Total of (Potentiality x Violations) / Total number of Violations