Franklin Smith - 6.2 Incident Report and Investigation Form

• Site conducted

  Select

• Date and Time of Incident

  Date

• Name of Injured Person

• Date Reported

  Date

• Incident Investigation Date

  Date

• Prepared by

• Location
  Address

• Risk Rating

  Extreme

  High

  Medium

  Low

• WorkSafe NZ Notifiable Event

  Yes

  No

Persons Involved in Investigation

Person

• Position

  Select Person Conducting Investigation Injured Person Other

  • Person Conducting Investigation
  • Injured Person
  • Other

• Name

Injury/Damage Sustained

• State here

Description of Incident

• Provide a brief description including sequence of events

• Has a similar incident/near miss occurred previously?

  Yes

  No

Key Contributing Factors

• Design of workplace/equipment (e.g defective or unsuitable equipment, workplace layout)

• Environment (e.g lighting, ventilation, noise, temperature)

• Human Factors (e.g lack of understanding, fatigue)

• Work methods and Systems (e.g training, unclear work procedures, flow of information)

• Other Comments - Ask the 5 Why’s to determine the Root Cause: Why did the event happen?...and Why was that?.....and Why was that?....and Why was that?......

Document Review (e.g procedures, interviews, photos)

Document

• Name of Document

• Attached

  Yes

  No

Corrective Actions

Action

• Specify Action

• Completion date

  Date

• Person Responsible

• Actions Completed

  Yes

  No