Information
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Incident Investigation
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Client / Site
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Conducted on
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Prepared by
GENERAL INFORMATION ABOUT THE INVESTIGATION
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Date investigation opened
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Investigated by:
(includes other employers)
investigator
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Name
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Email
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Phone
GENERAL INFORMATION ABOUT THE INCIDENT
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Date and time of incident (if known)
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Location (Be as specific as possible. Include address, building name, room number, etc. as appropriate)
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Briefly describe the location (i.e. "classroom", "lab", "outdoor constuction", etc)
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Briefly describe the incident.
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Did the incident result in any of the following? (check all that apply)
- Fatality
- Serious/permanent injury or illness
- Non-Serious injury or illness
- Property damage
- Near miss
WITNESS(ES)
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Were there any winesses to the incident?
Victim
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Employer/Department or Job Title
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Phone
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E-mail
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Does this witnesses account of the incident support the victim's account?
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Explain.
VICTIM AND WITNESS STATEMENTS
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Were there any victims in the incident?
Victim
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Name
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Date of Birth
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Employer/Department or Job Title
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Phone
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E-mail
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Was this person physically injured?
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If this person is employed by Harris Companies, has a first report of injury been submitted to the corporate safety management team?
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Describe the injuries. Be as specific as possible.
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Did this person receive medical treatment beyond first aid?
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Name
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Hospital/Clinic/Physician
THE WORK ENVIRONMENT
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Was the work environment a factor in this incident?
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Explain:
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Add media
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Provide a diagram of the work environment(as appropriate)
MACHINES, EQUIPMENT, VEHICLES
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Were any machines, equipment, or vehicles involved in the incident?
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Please provide information on each machine, piece of equipment, or vehicle
machine, equipment, vehicle
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Short description (i.e. "2012 Ford Explorer", "6 foot step ladder", "radial arm saw")
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Manufacturer
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Model
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Year/date of manufacture if known
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Serial number/Vehicle Identification Number (VIN)/Other unique identifier
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Who owns this machine/equipment/vehicle?
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Who was operating/in control of the machine, equipment, or vehicle at the time of the incident?
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What was the general condition of the machine, equipment, or vehicle at the time of the incident?
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Describe any defects, violations, deficiencies or hazards noted in the machine, equipment, or vehicle that might have contributed to the incident?
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Describe any relevant modifications.
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Does this machine, equipment, or vehicle have any known history of defects or other accidents?
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Has this machine, equipment, or vehicle ever been inspected?
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by whom?
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When was the most recent inspection?
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What were the findings?
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Are there records of this inspection? Where are they? Who has them?
PERSONAL PROTECTIVE EQUIPMENT (PPE)
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Is PPE, or lack thereof, a factor in this incident?
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Is there any req. for PPE, such an OSHA regulation, a workplace rule, an SOP, a sign/placard?
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Describe the rule/guideline.
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Was the employee in compliance with those rules? Why/Why not? What PPE was in use? Include make, model, size, style. in the case of hearing protection , include NRR. In the case of respiratory protection, include cartridge and filter information, as well as recent change out details.
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Had rules regarding PPE been communicated to employee at time of hire and at least annually thereafter?
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Describe. Include dates. Was training documented?
UNSAFE/AT-RISK BEHAVIORS AND ACTIONS
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Was an unsafe/at-risk behavior or action a factor in the incident?
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Describe:
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Is there a specific formal safety rule or OSHA regulation that was violated?
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Describe:
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Was this rule/regulation communicated to the employee? how? when? was this documented?
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Has disciplinary action been taken? Describe.
CORRECTIVE ACTION PLAN
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What corrective measures will be taken to ensure this incident does not occur again?
SUBROGATION
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Are there opportunities for subrogation in this case?
Subrogation opportunity
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Name/Company
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Reason/justification
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Has all physical evidence been secured, photographed, or otherwise preserved?