• Title

  • Site

  • Conducted on

  • Prepared by

  • Location

Investigation Details

Incident Investigation

  • Take as many photos of the scene as possible.

  • Describe, in detail, what occurred. Include the exact task being done and any relevant events leading up to the incident.

  • What type of incident occurred?

  • Date and time of incident

  • Date and time employee began work

  • Name of Injured Employee

  • Department and Shift of Injured Employee

  • Employment Status of Injured Person

  • What object/substance directly injured the employee

  • Was on-site first aid treatment given?

  • Who administered first aid?

  • What first aid was performed? (ice, bandage, anti-bacterial cream, etc.)

  • 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?

  • What part of body was injured?

  • Were safeguards, safety equipment, or PPE being used prior to the incident?

  • Were safeguards, safety equipment, or PPE provided?

Root Cause Analysis (5 Why's)

  • Is Root Cause Analyses required?

  • Why?

  • Why
  • Answer

  • What is the root cause of this incident?

Immediate Corrective Action

  • 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.


  • Preparers signature

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.