Title Page

  • Revision Level

  • Author

  • Date

  • Document Number

Incident Investigation

Incident Investigation

  • Type of Report

  • Name of Injured Person

  • Position

  • Employee Number

  • Telephone Number

  • Employment Type

  • Date and Time of Incident

  • 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.

Corrective Actions

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

  • Short Term / Immediate

  • Person Responsible

  • Completion Date

  • Long Term / Permanent

  • Person Responsible

  • Completion Date

Incident Review Meeting

  • Facility Manager

  • Date

  • Notify Regional Manager

  • Regional Manager

  • Date

  • Notify Health and Safety

  • Health and Safety

  • Date

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