Incident Investigation Form

• Revision Level

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• Author

  Select

• Date

  Date

• Document Number

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Incident Investigation

• Type of Report

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• Name of Injured Person

• Position

• Employee Number

• Telephone Number

• Employment Type

  Select

• Date and Time of Incident

  Date

• Address

• Attach form HS-F-003

• Witnesses (if any) List all Witnesses.

• Explain the Incident and Root Cause in your own words.

• What were the contributing factors to the incident.

  Select

Corrective Actions

• Corrective Action to Prevent Reoccurrence of the Root Cause - List Actions Taken

• Short Term / Immediate

• Person Responsible

• Completion Date

  Date

• Long Term / Permanent

• Person Responsible

• Completion Date

  Date

Incident Review Meeting

• Facility Manager

  Sign

• Date

  Date

• Notify Regional Manager

  Notify

• Regional Manager

  Sign

• Date

  Date

• Notify Health and Safety

  Notify

• Health and Safety

  Sign

• Date

  Date