Incident Investigation

• Conducted on

  Date

• Prepared by

• Person/s Consulted With

• Location
  Address

• Injured Persons Name

• Incident Date

• Incident Report Number

• Incident Investigation Number

• Has the injured person been contacted following the incident?

  Yes

  No

• If no, what is the reason?

• Did the injured person seek further medical treatment?

  Yes

  No

• What is the current status of their injury?

• Was assistance offered?

  Yes

  No

• Was offer of assistance accepted?

  Yes

  No

• Type of assistance provided

  Yes

  No

  N/A

• If assistance was declined please explain why

• Was there any damage to property?

  Yes

  No

• If yes, please detail.

• Has any property damage been rectified?

  Yes

  No

• Were Emergency Services required to deal with the incident?

  Yes

  No

• Has an emergency services event number been recorded?

  Yes

  No

• Yes

  No

• If yes, list

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

  Yes

  No

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

  Yes

  No

• What exactly happened?

• Where did it happen?

• Who was involved?

• How did it happen?

• Why did it happen?

• 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

  Date

Directive Causes & Causal Factors

• List corrective actions to address root causes

• Who is responsible for implementing corrective actions?

• Due Date

  Date

Preventative Measures for Root Causes

• List preventative measures to address root causes

• Who is responsible for implementing preventative measures?

• Due Date

  Date

• Describe Actions to Ensure Proper Sharing / Communication

• Is an ICCAM investigtion required?

  Yes

  No

• Final Closure Date and Time

  Date

• Verified By

• Signed

  Sign