For All Incidents

Has the injured person been contacted following the incident?

If no, what is the reason?

Did the injured person seek further medical treatment?

What is the current status of their injury?

Was assistance offered?

Was offer of assistance accepted?

Type of assistance provided

If assistance was declined please explain why

Was there any damage to property?

If yes, please detail.

Has any property damage been rectified?

Were Emergency Services required to deal with the incident?

Has an emergency services event number been recorded?

If yes, list

Has the contact information for all person's involved in the incident been added to the incident report?

Have witness statements been obtained from all relevant person's?

Incident Details

What exactly happened?

Where did it happen?

Who was involved?

How did it happen?

Why did it happen?

Interim Containment

What immediate or emergency actions are taken to mitigate risk of recurrence of incident that lead to injury?

Who is responsible for implementing immediate actions?

Due Date

Corrective Actions

Directive Causes & Causal Factors

List corrective actions to address root causes

Who is responsible for implementing corrective actions?

Due Date
Preventative Measures for Root Causes

List preventative measures to address root causes

Who is responsible for implementing preventative measures?

Due Date

Describe Actions to Ensure Proper Sharing / Communication

Closure

Is an ICCAM investigtion required?

Final Closure Date and Time

Verified By

Signed
Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.