• Document No.

  • Formal Investigation Report Number

  • Flexible Films Division

  • Forming Films Division

  • CL Polymers

  • Conducted on

  • Prepared by

Data Capture

Incident information

  • Incident Number

  • Date and Time of Occurrence

  • Check if date or time cannot be determined or is unknown.

  • Date and Time Reported

  • Location of Incident

Investigation Information

  • Date and time of Formal Investigation

  • Investigation Committee

Narrative Description

  • Witnesses

  • Describe What Occurred

  • Add photo


Contributing Causes

  • List the proximate cause of the incident.

  • List the Root Cause(s)

Recommendations (List at least three)

  • Recommendation 1

  • Responsible Party

  • To Be Completed By

  • Recommendation 2

  • Responsible Party

  • To Be Completed By

  • Recommendation 3

  • Responsible Party

  • To Be Completed By

  • Recommendation 4

  • Responsible Party

  • To Be Completed By

Signature of Investigation Committee Chair

  • Add signature

  • Select date

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.