Information

  • Incident Investigation

  • Client / Site

  • Conducted on

  • Prepared by

GENERAL INFORMATION ABOUT THE INVESTIGATION

  • Date investigation opened

  • Investigated by:
    (includes other employers)

  • investigator
  • Name

  • Email

  • Phone

GENERAL INFORMATION ABOUT THE INCIDENT

  • Date and time of incident (if known)

  • Location (Be as specific as possible. Include address, building name, room number, etc. as appropriate)

  • Briefly describe the location (i.e. "classroom", "lab", "outdoor constuction", etc)

  • Briefly describe the incident.

  • Did the incident result in any of the following? (check all that apply)

WITNESS(ES)

  • Were there any winesses to the incident?

  • Victim
  • Employer/Department or Job Title

  • Phone

  • E-mail

  • Does this witnesses account of the incident support the victim's account?

  • Explain.

VICTIM AND WITNESS STATEMENTS

  • Were there any victims in the incident?

  • Victim
  • Name

  • Date of Birth

  • Employer/Department or Job Title

  • Phone

  • E-mail

  • Was this person physically injured?

  • If this person is employed by Harris Companies, has a first report of injury been submitted to the corporate safety management team?

  • Describe the injuries. Be as specific as possible.

  • Did this person receive medical treatment beyond first aid?

  • Name

  • Hospital/Clinic/Physician

THE WORK ENVIRONMENT

  • Was the work environment a factor in this incident?

  • Explain:

  • Add media

  • Provide a diagram of the work environment(as appropriate)

MACHINES, EQUIPMENT, VEHICLES

  • Were any machines, equipment, or vehicles involved in the incident?

  • Please provide information on each machine, piece of equipment, or vehicle

  • machine, equipment, vehicle
  • Short description (i.e. "2012 Ford Explorer", "6 foot step ladder", "radial arm saw")

  • Manufacturer

  • Model

  • Year/date of manufacture if known

  • Serial number/Vehicle Identification Number (VIN)/Other unique identifier

  • Who owns this machine/equipment/vehicle?

  • Who was operating/in control of the machine, equipment, or vehicle at the time of the incident?

  • What was the general condition of the machine, equipment, or vehicle at the time of the incident?

  • Describe any defects, violations, deficiencies or hazards noted in the machine, equipment, or vehicle that might have contributed to the incident?

  • Describe any relevant modifications.

  • Does this machine, equipment, or vehicle have any known history of defects or other accidents?

  • Has this machine, equipment, or vehicle ever been inspected?

  • by whom?

  • When was the most recent inspection?

  • What were the findings?

  • Are there records of this inspection? Where are they? Who has them?

PERSONAL PROTECTIVE EQUIPMENT (PPE)

  • Is PPE, or lack thereof, a factor in this incident?

  • Is there any req. for PPE, such an OSHA regulation, a workplace rule, an SOP, a sign/placard?

  • Describe the rule/guideline.

  • 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.

  • Had rules regarding PPE been communicated to employee at time of hire and at least annually thereafter?

  • Describe. Include dates. Was training documented?

UNSAFE/AT-RISK BEHAVIORS AND ACTIONS

  • Was an unsafe/at-risk behavior or action a factor in the incident?

  • Describe:

  • Is there a specific formal safety rule or OSHA regulation that was violated?

  • Describe:

  • Was this rule/regulation communicated to the employee? how? when? was this documented?

  • Has disciplinary action been taken? Describe.

CORRECTIVE ACTION PLAN

  • What corrective measures will be taken to ensure this incident does not occur again?

SUBROGATION

  • Are there opportunities for subrogation in this case?

  • Subrogation opportunity
  • Name/Company

  • Reason/justification

  • Has all physical evidence been secured, photographed, or otherwise preserved?

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.