Information
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Title
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Tracking Number:
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Location within building
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Conducted on
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Prepared by
Investigation Details
Incident Investigation
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Take as many photos of the scene as possible.
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Describe, in detail, what occurred. Include the exact task being done and any relevant events leading up to the incident.
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What type of incident occurred?
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Date and time of incident
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Department of injured employee?
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Length of Employment
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What object/substance directly injured the employee
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Was on-site first aid treatment given?
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What first aid was performed? (ice, bandage, anti-bacterial cream, etc.)
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Did the employee ask/accept potential treatment beyond first aid with a TMC authorized provider?
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Was this a recordable injury/illness?
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Investigator: Describe the nature of the damaged equipment. What was damaged? To what extent? Is the equipment operable? Does it pose additional risk to operators in it's current state?
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Date and time of incident
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Name of Employee
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Department of Employee
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Length of Employment
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What part of body could have been injured?
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Date and time of incident
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Name of Employee
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Department of Employee
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Length of Employment
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What object/substance directly injured or could have injured the employee?
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Were safeguards, safety equipment, or PPE being used prior to the incident?
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Were safeguards, safety equipment, or PPE provided?
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Were processes/policy being followed when incident occured?
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Describe abnormalities or reasons why policy was circumvented.
Why did the incident occur?
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Provide reason or rationale for why the incident occured.
Corrective Action
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Enter corrective actions taken to prevent immediate reoccurrence. Enter suggestions for future corrective actions. Each "Why" in the previous section may result in a corresponding corrective action.
