Title Page

  • Document No.

  • Audit Title

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Personnel

Incident Information

  • Investigators

  • Employees involved and date contacted

  • Summary of Incident

  • Add media

General Incident Questions

  • Was there mechanical failure?

  • Was there a procedure to follow?

  • We're safeguards used?

  • In what area does this incident raise concerns?

  • Does the employee have suggestions to avoid a similar incident in the future?

Specific Questions

  • Every incident is different and therefore questions must be tailored to the incident. Please use this section to record additional questions asked and their answers.

Incident Investigation Summary

  • Recommendations / Findings

  • The 5 Whys Analysis. The first why is the direct cause of the incident. Continue to ask "WHY" for the next four or five answers to eventually reach the root cause.

  • Undesired event

  • Why did the incident happen? (Direct cause)

  • Why did this occur? (Contributing cause)

  • Why did that occur?(Contributing cause)

  • Why did this occur? (Contributing cause)

  • Why did that occur? (Contributing cause)

  • Root Cause:

  • Corrective Actions:

Follow Up Actions

  • Select date

  • Add signature

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.