Title Page

  • Site conducted

  • Investigation Date

  • Investigator(s)



    1. Please answer all questions below.
    2. Add Photos in "Media" and Comments in "Add note..." on each question as needed.
    3. When complete, please email Nic Schmitt and the Safety Team Leads on each shift, notifying them that the report is ready in iAuditor.

Initial Information

  • Injured Team Member Name

  • Injured Team Member Clock Number

  • Date Incident Occurred

  • Supervisor Who Filled out the Corporate Injury Investigation Report

Sequence of Events (Incident Should be the Last Event): Facts of what occurred up to incident

  • 01 What Happened?

  • Cause/Why?

  • 02 What Happened?

  • Cause/Why?

  • 03 What Happened?

  • Cause/Why?

  • 04 What Happened?

  • Cause/Why?

  • 05 What Happened?

  • Cause/Why?

  • 06 What Happened?

  • Cause/Why?

Additional Information

  • Tool/Machine Involved?

  • What Machine?

  • Material/Product Involved?

  • What (gauge/thickness, size, weight, model, color, SO#, PO#)

  • Workstation Height Relative to Team Member?

  • Unsafe Behavior (Example: Improper Hand Placement, Awareness)?

  • Environment (Outside Conditions, Lighting, Substance on Floor, etc.)?

Root Cause

  • What is the root cause?

Corrective Action (this will be discussed with the safety team)

  • What is a possible corrective action?

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.