Title Page
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Document No.
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Audit Title
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Client / Site / Project
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Investigation conducted on
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Prepared by
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Location
Incident Details
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Date & Time of Incident
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Location of Incident
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Incident Severity?
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Incident Type (select all that apply)
- Hazard
- Near-Miss
- Slip & Fall
- Accident
- Injury
- Theft
- Fire
- Property Damage
- Fatality
- Illness
- Reportable / Notifiable
- Loss Time
- Other
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Please describe type of incident
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Name of on-duty supervisor at time of incident?
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Was medical attention administered?
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What kind of medical attention was administered?
- First Aid
- Doctor Consulted
- Hospital
- Ambulance
- Medical Attention Declined
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Please detail medical attention
Incident Summary
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Describe what happened. Please be detailed but state only facts.
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Describe relevant environmental factors, such as weather.
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Do you wish to include a timeline of events for this incident?
Incident Timeline
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Build a timeline of key incident events below
Event
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Event Date / Time
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Event Description
Evidence and Attachments
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Which of the following do you need to attach to this report to accuractly document this incident?
- Evidence
- Equipment Details
- Vehicle Details
- Damages
- Other Items
Evidence Log
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Do you need to attach any photos or log evidence to this incident report?
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Please log all relevant evidence below
Evidence
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Evidence Description
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Evidence ID number (if applicable)
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Type of evidence
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Photos of evidence (if applicable)
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Please detail any further information regarding this evidence (if applicable)
Vehicle Log
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Do you need to log any vehicle information to this incident report?
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Please log all relevant vehicle details below
Vehicle
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Vehicle Make
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Vehicle Model
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Vehicle Registration
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Driver (if applicable)
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Photos of equipment (if applicable)
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Please detail any further information regarding this vehicle (if applicable)
Damage Log
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Do you need to log any damage information to this incident report?
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Please log all relevant damage details below
Damage
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Damage description
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ID number (if applicable)
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Photos of damage (if applicable)
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Please detail any further information regarding this damage (if applicable)
Other Items Log
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Do you need to log any other items to this incident report?
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Please log all relevant details of other items below
Item
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Item description
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ID number (if applicable)
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Photos of item (if applicable)
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Please detail any further information regarding this item (if applicable)
Equipment Log
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Do you need to log any equipment information to this incident report?
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Please log all relevant equipment details below
Equipment
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Equipment Make
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Equipment Model
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Equipment ID number (if applicable)
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Photos of equipment (if applicable)
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Please detail any further information regarding this equipment (if applicable)
People involved
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Please document all people involved in this incident
Person
Person
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Full Name
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ID number
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Contact phone number
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What is this person's relation to the incident? (select all that apply)
- Reporter of incident
- Injured person
- Witness
- Primary person involved
- Secondary Involvement
- On-duty supervisor
- Investigator
- Suspect
- Other
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Describe this person's relation to the incident
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Please describe this person's involvement with the incident, including all relevant information
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Attach any relevant photos regarding this person
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Does this person wish to make a statement?
Statement
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Statement regarding incident
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Person Signature
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Date & Time of Statement
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Has this person sustained an injury?
Injury Details
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Type of injury or illness? (select all that apply)
- Superficial
- Open Wound
- Fatality
- Concussion
- Sprain
- Respiratory
- Eye Injury
- Burns
- Fracture
- Electrocution
- Fall
- Strain
- Dislocation
- Struck by object
- Entanglement
- Assault
- Muscle & Tendon
- Nerve & Spinal Cord
- Amputation
- Intracranial
- Other
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Describe type of injury or illness
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Parts of body affected? (select all that apply)
- General Ailment
- Head
- Eye (Right)
- Eye (Left)
- Ear
- Nose
- Throat
- Neck
- Back (Upper)
- Back (Lower)
- Arm - Upper (Right)
- Arm - Upper (Left)
- Arm - Elbow (Right)
- Arm - Elbow (Left)
- Arm - Forearm (Right)
- Arm - Forearm (Right)
- Wrist (Right)
- Wrist (Left)
- Hand (Right)
- Hand (Left)
- Chest
- Abdominal / Stomach
- Groin / Anus
- Leg - Upper (Right)
- Leg - Upper (Left)
- Leg - Knee (Right)
- Leg - Knee (Left)
- Leg - Lower (Right)
- Leg - Lower (Left)
- Ankle (Right)
- Ankle (Left)
- Foot (Right)
- Foot (Left)
- Shoulder (Left)
- Shoulder (Right)
- Other
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Please describe injury location
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Describe this injury or illness
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What was the cause of this injury or illness?
Corrective Actions
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Are corrective/further actions required with regard to this incident?
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Please add any corrective actions to the question above before completing this incident investigation
Root Cause Analysis / Contributing Factors
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What were the contributing factors to this incident occurring? (select all that apply)
- Equipment Defects
- Unauthorized Equipment Use
- Improper Equipment Use
- Lack of protective safety devices
- Employee operating at inappropriate speed
- Equipment used outside rated capacity
- Lack of PPE
- Inappropriate PPE
- Untidy Conditions (Poor Housekeeping)
- Safety procedures not followed
- Inadequate ventilation
- Drugs or Alcohol
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Has the root cause of this issue been able to be identified?
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Why is the root cause for this issue unable to be identified at this time?
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How likely is this incident to reoccur in future?
- Certain
- Very Likely
- Likely
- Unlikely
- Very Unlikely
- Never
- Unclear / Not Determinable
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What is the root cause of this incident? Please consider and include all contributing factors
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Has the root cause of this issue been rectified or eliminated?
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How was the root cause rectified or eliminated?
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Please attach any relevant photos or media
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Please provide any relevant further details
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How likely is this incident to reoccur in future?
- Certain
- Very Likely
- Likely
- Unlikely
- Very Unlikely
- Never
- Unclear / Not Determinable
Sign Off
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Further action/follow-up/investigation required?
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Name of person/people to follow up
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Name of Investigator
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Signature of Investigator
