Enertek Incident Investigation Report

Enertek Energy Services Incident Investigation Report

• Report Name:

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

• Location

• Job #:

• Date of occurrence

  Date

• Date reported

  Date

• 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

Injury

• Did an Injury occur?

  Yes

  No

  N/A

• Nature of Injury

• Body Part Affected

• Was follow-up treatment required?

  Yes

  No

  N/A

Person Involved

• Was there a person(s) directly involved?

  Yes

  No

  N/A

• Worker Name

• Worker Position

• Worker Age

• Worker Contact Number

• Worker Experience (Years) in position:

Description

• Clearly describe how the incident occurred.

Pictures

• Were there pictures taken?

  Yes

  No

  N/A

• Add media

  Media

Witnesses

• Were there any witness's to the event?

  Yes

  No

  N/A

• Witness Name, Contact Info. Attach signed witness statement

Analysis

• 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)

Prevention

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

Frequency Potential

• Frequent

• Probable

• Occasional

• Remote

Severity

• Serious

• Moderate

• Minor

Costs

• Estimated:

• Actual:

Conclusion

• Extra comments

• Investigated by:

  Sign

• Investigated by:

  Sign