ICS Incident Investigation

• Injured Employee's Name

• Job Name/Number

• Date/Time of Injury

  Date

• Date/Time Safety Manager was notified

  Date

• Investigation Prepared by

  Sign

• Injured Employee's Job Title

• Who is the Controlling Contractor on site

• Is the project an OCIP, CCIP, or WRAP Insurance Program

  Yes

  No

  N/A

Accident Investigation

• Where the event occurred (e.g. Loading dock north end)

• Describe injury/illness & parts of the body affected (e.g. Second degree burns on my right forearm from an acetylene torch)

• What object/substance directly injured the employee (e.g. The ladder from falling down on top of them)

• What was the result of the injury/illness (e.g. Laceration to the top of my right hand)

• Were was the employee treated (e.g. clinic/hospital or on the job site first aid)

• Was the proper PPE worn?

  Yes

  No

  N/A

• (Root Cause) What were the Root Causes of this injury/illness (e.g. Main cause 1st)

• (Corrective Action) What has been done to prevent a similar accident from occurring again

• (Re-Training) What is the topic(s) that are being trained on to prevent this incident/illness from occurring again

• (Disciplinary Action) What disciplinary action has been taken (When Applicable)

• Injury Classification

  Select First Aid (ICS Only) On-Site Health & Safety or First Aid Response on-site treatment Medical Aid at Clinic Recordable Injury

  • First Aid (ICS Only)
  • On-Site Health & Safety or First Aid Response on-site treatment
  • Medical Aid at Clinic
  • Recordable Injury

• Is this an OSHA Reportable Incident

  Yes

  No

  N/A

• Red Flag - Do you disagree with the validity of this claim (If Yes, provide an explanation)

  Yes

  No

  N/A