Enertek Energy Services Incident Investigation Report

  • Report Name:

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Personnel

  • Location

  • Job #:

  • Date of occurrence

  • Date reported

  • Employee?

  • Subcontractor?

Type of Incident. Select all that apply.

  • Near Miss

  • First Aid

  • Medical Aid

  • Restricted Work

  • Lost Time

  • Occupational Illness

  • Fire or Explosion

  • Equipment Failure

  • Property Damage

  • Material or Business Loss

  • Motor Vehicle Accident

  • Other


  • Did an Injury occur?

  • Nature of Injury

  • Body Part Affected

  • Was follow-up treatment required?

Person Involved

  • Was there a person(s) directly involved?

  • Worker Name

  • Worker Position

  • Worker Age

  • Worker Contact Number

  • Worker Experience (Years) in position:


  • Clearly describe how the incident occurred.


  • Were there pictures taken?

  • Add media


  • Were there any witness's to the event?

  • Witness Name, Contact Info. Attach signed witness statement


  • Immediate causes, what acts failure to act, and conditions contributed directly to this accident?

  • Basic causes, what are the contributing factors? (Job factors, personal factors)


  • What action or recommendations are made to prevent recurrence? When? And action by?

Frequency Potential

  • Frequent

  • Probable

  • Occasional

  • Remote


  • Serious

  • Moderate

  • Minor


  • Estimated:

  • Actual:


  • Extra comments

  • Investigated by:

  • Investigated by:

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