Enertek Incident Investigation Report

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

• Location

• Job #:

• Date of occurrence

  Date

• Date reported

  Date

• This incident involved:

  Select Enertek Property or Employee Client Property or Employee Subcontractor Property or Employee Multiple

  • Enertek Property or Employee
  • Client Property or Employee
  • Subcontractor Property or Employee
  • Multiple

• Please choose all that apply.

  Select Enertek Property Enertek Employee Enertek Subcontractor Client Property Client Employee Client Subcontractor

  • Enertek Property
  • Enertek Employee
  • Enertek Subcontractor
  • Client Property
  • Client Employee
  • Client Subcontractor

Type of Incident. Select all that apply.

• Type of incident. May be multiple types.

  Select Near Miss First Aid Medical Aid Restricted Work Lost Time Occupational Illness Fire or Explosion Equipment Failure Property Damage Material or Business Loss Theft or Harrassment Other

  • Near Miss
  • First Aid
  • Medical Aid
  • Restricted Work
  • Lost Time
  • Occupational Illness
  • Fire or Explosion
  • Equipment Failure
  • Property Damage
  • Material or Business Loss
  • Theft or Harrassment
  • Other

Injury

• Were there any injuries?

  Yes

  No
Type of injury?

• Add media

  Media

Person(s) Directly Involved With The Incident.

• Were there people involved in the incident?

  Yes

  No
Please enter the names of those involved.

• Employee name

• Date of Birth

• Address

Witnesses

• Were there any witnesses to the incident?

  Yes

  No
Please enter the names of those involved.

• Employee name

• Date of Birth

• Address

Description

• Clearly describe how the incident occurred.

• Add media

  Media

• Add drawing

  Drawing

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

• The Frequency Potential is:

  Frequent

  Probable

  Occasional

  Remote

Severity

• The Severity Potential is:

  Serious

  Moderate

  Minor

Costs

• Estimated:

• Actual:

Conclusion

• Extra comments

• Extra Media

  Media

• Investigated by:

  Sign

• Investigated by:

  Sign