Title Page
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Document No.
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Site
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Investigation title
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Conducted on
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Prepared by
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Employee
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Employee address
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Employee phone number
Investigation
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Status of injury
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Employee category
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Length of employment
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Employee's usual job position
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Length at this position
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Was the employee trained in the position that they were working at the time of the incident?
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Was the employee working within the scope of their normal job position?
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JSA completed for the job employee was doing at the time of the incident
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Area where incident occured
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On CPI property
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Date and time of incident
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Phase of employee's workday at the time of the incident
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Investigation team
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Nature of Incident
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Add media
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Facts resulting from the investigation
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Add media
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Contributing cause
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Add media
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Root cause
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Add media
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Corrective action/Responsibility
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Complete by
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Add signature
