Incident Investigation

• Title

• Site

• Conducted on

  Date

• Prepared by

• Location
  Address

Incident Investigation

• Take as many photos of the scene as possible.

  Media

• 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?

  Injury

  Illness

  Near Miss

• Date and time of incident

  Date

• Date and time employee began work

  Date

• Name of Injured Employee

• Department and Shift of Injured Employee

• Employment Status of Injured Person

  Permanent

  Intern

  Contractor

• What object/substance directly injured the employee

• Was on-site first aid treatment given?

  Yes

  No

  N/A

• 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?

  Yes

  No

  N/A

Root Cause Analysis (5 Why's)

• Is Root Cause Analyses required?

  Yes

  No

• 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.

Finalization

• Preparers signature

  Sign