Information

  • Investigation No.

  • ETIR Title

  • Conducted on

  • Prepared by

  • Location
  • Incident Location

  • Job #:

  • Date of occurrence

  • Date Reported

  • Reported by? Name, work location,phone number.

  • Energy Solutions Employee?

  • Contractor?

Type of Incident. Select all that apply.

  • Lost Time Injury?

  • Medical Treatment injury?

  • First aid Injury?

  • Occupational Illness?

  • Environmental?

  • Fire or Explosion?

  • Equipment Failure?

  • Property Damage?

  • Material or Business Loss

  • Restricted Work Injury ?

  • Motor Vehicle Accident

  • Threats?

  • Other

Injury description (if applicable)

  • What type of injury?

  • What body part was injured?

  • Was follow-up treatment required?

Person(s) Involved

  • Employee name(s)

Description

  • Does the Investigation clearly describe how the incident occurred.

  • Were Immediate actions taken appropriate?

Analysis

  • Investigation Team suitably experienced to conduct the investigation

  • Background Information contains detailed information on prior conditions

  • all people involved interviewed?

  • Environmental conditions suitably assessed?

  • Equipment / Plant /Tools identified and considered

  • Procedures in place and followed?

  • Procedures reviewed and found suitable or change identifed?

  • Organisational Factors identified and considered?

  • Task /Environmental conditions identified and considered?

  • Individual / Team actions identified and considered?

  • Absent / Failed defences identified and considered?

  • Conclusion identified and considered factual and suitable

  • Root cause identified and appropriate?

Prevention

  • Corrective action plan established?

  • Corrective action(s) identified suitable to prevent re ocurrence?

  • Recommendation identified and suitable to prevent reoccurrence?

  • All actions from action plan assigned to a person with a completion date

  • What action or recommendations have been implemented to prevent recurrence? When? And actioned by?

  • Evidentiiary docs e.g. Licenses,qualifications, Incident photos etc included within the ICAM investigation?

  • Learnings shared with other sites?

Conclusion

  • ETIR Team comments and recommendations

  • Add media

  • ETIR Team Members:

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.