Title Page

  • Location

  • Room number (silver disk on top of door)

  • Team members present

  • Date / Time

  • Description of incident

Incident Information

  • Initial containment (Emergency actions to prevent further harm/damage) Please create and assign actions to enable containment progress tracking

  • Required standard (Describe specification, policy, procedure or expectation) - What should have happened?

  • Problem statement (What is wrong with what? What is the impact? How has the required standard not been met?)

Why?

  • Why did the problem occur?

  • Why?

  • Why?

  • Why?

  • Why?

Root Cause

  • Summary of root cause

  • Corrective & Preventive Actions (These must address the failure mechanism and modify systems to prevent recurrence) Please create and assign actions to enable progress tracking

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.