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

Discussion

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

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