Title Page

Title of Inspection

  • Incident Type

  • Affected Employee:

  • Affected Employee:

  • Affected Employee:

  • Condition and Location:

  • Behavior Observed:

  • Employee Name:

  • Condition and Location

Incident Report

  • Please select the type of incident:

  • Department

  • Process Area

  • Process Area

  • Describe Location

  • Employee Name

  • Date and Time of Incident

  • Date Reported

  • Shift

  • Time Employee Began Work

  • Employees usual job title

  • Job at time of incident

  • Length of time on the job before the incident had occurred

  • Describe in detail how the incident occured:

  • Add pictures from incident here:

  • Describe the work in progress (task) when the incident occurred

  • Did anyone witness the incident?

  • Who?

  • Were statements recorded at the Nurse's station?

  • Potential result of an incident

  • Potentially contacted with/contacted by

  • Reference: Complete List of all Causal Factors

    Causal Factors 2.JPG
  • Causal Factor(s)

  • Employee

  • Supervision

  • Equipment/Materials

  • Other

  • Basic Cause(s)

  • Immediate fix

5 Why (Root Cause)

  • 1. Why did the incident happen?

  • 2. Why did 1 happen?

  • 3. Why did 2 happen

  • 4. Why did 3 happen?

  • 5. Why did 4 happen?

Corrective Actions

  • Do the documented practices and assessments adequately cover the situation to prevent re-occurrence?

  • If no, develop a corrective action

  • Is the incident recordable and behavioral?

  • If yes, develop a corrective action

  • Is this incident a re-occurrence?

  • If yes, develop a corrective action to address the re-occurrence and learn from what did not work last time

  • Supervisor Corrective Action #1

  • Responsible Person

  • Target Date

  • Supervisor Corrective Action #2

  • Responsible Person

  • Target Date

  • Supervisor Corrective Action #3

  • Responsible Person

  • Target Date

  • Employee Signature

  • Supervisor Signature

  • Department Manager

  • ORM Manager

  • Department

  • Process Area

  • Process Area

  • Describe Location

  • Employee Name

  • Date and Time of Incident

  • Date Reported

  • Shift

  • Time Employee Began Work

  • Employees usual job title

  • Job at time of incident

  • Length of time on the job before the incident had occurred

  • Describe in detail how the incident occured:

  • Add pictures from incident here:

  • Describe the work in progress (task) when the incident occurred

  • Did anyone witness the incident?

  • Who?

  • Were statements recorded at the Nurse's station?

  • Incident Type

  • Contacted With/Contacted By

  • Right or Left Side of Body?

  • Right - Body Part Affected

  • Left - Body Part Affected

  • Nature of Injury

  • Nature of Illness

  • Reference: Complete List of all Causal Factors

    Causal Factors 2.JPG
  • Causal Factor(s)

  • Employee

  • Supervision

  • Equipment/Materials

  • Other

  • Basic Cause(s)

  • Immediate fix

5 Why (Root Cause)

  • 1. Why did the incident happen?

  • 2. Why did 1 happen?

  • 3. Why did 2 happen

  • 4. Why did 3 happen?

  • 5. Why did 4 happen?

Corrective Actions

  • Do the documented practices and assessments adequately cover the situation to prevent re-occurrence?

  • If no, develop a corrective action

  • Is the incident recordable and behavioral?

  • If yes, develop a corrective action

  • Is this incident a re-occurrence?

  • If yes, develop a corrective action to address the re-occurrence and learn from what did not work last time

  • Supervisor Corrective Action #1

  • Responsible Person

  • Target Date

  • Supervisor Corrective Action #2

  • Responsible Person

  • Target Date

  • Supervisor Corrective Action #3

  • Responsible Person

  • Target Date

  • Employee Signature

  • Supervisor Signature

  • Department Manager

  • ORM Manager

  • Department

  • Process Area

  • Process Area

  • Describe Location

  • Employee Name

  • Date and Time of Incident

  • Date Reported

  • Shift

  • Time Employee Began Work

  • Employees usual job title

  • Job at time of incident

  • Length of time on the job before the incident had occurred

  • OSHA Class

  • Describe in detail how the incident occurred:

  • Add pictures from incident here:

  • Describe the work in progress (task) when the incident occurred

  • Did anyone witness the incident?

  • Who?

  • Were statements recorded at the Nurse's station?

  • Incident Type

  • Contacted With/Contacted By

  • Description of Injury/Illness

  • Right or Left Side of Body?

  • Right - Body Part Affected

  • Left - Body Part Affected

  • Nature of Injury

  • Nature of Illness

  • Reference: Complete List of all Causal Factors

    Causal Factors 2.JPG
  • Causal Factor(s)

  • Employee

  • Supervision

  • Equipment/Materials

  • Other

  • Basic Cause(s)

  • Immediate fix

5 Why (Root Cause)

  • 1. Why did the incident happen?

  • 2. Why did 1 happen?

  • 3. Why did 2 happen

  • 4. Why did 3 happen?

  • 5. Why did 4 happen?

Corrective Actions

  • Do the documented practices and assessments adequately cover the situation to prevent re-occurrence?

  • If no, develop a corrective action

  • Is the incident recordable and behavioral?

  • If yes, develop a corrective action

  • Is this incident a re-occurrence?

  • If yes, develop a corrective action to address the re-occurrence and learn from what did not work last time

  • Supervisor Corrective Action #1

  • Responsible Person

  • Target Date

  • Supervisor Corrective Action #2

  • Responsible Person

  • Target Date

  • Supervisor Corrective Action #3

  • Responsible Person

  • Target Date

  • Employee Signature

  • Supervisor Signature

  • Department Manager

  • ORM Manager

  • Damage to company property will result in disciplinary action based on the following.

    Capture.JPG
  • Department

  • Process Area

  • Process Area

  • Describe Location

  • Employee(s) Name

  • Date and Time of Incident

  • Date Reported

  • Shift

  • Time Employee(s) Began Work

  • Employees usual job title

  • Job at time of incident

  • Length of time on the job before the incident had occurred

  • Describe in detail how the incident occured:

  • Add pictures from incident here:

  • Describe the work in progress (task) when the incident occurred

  • Did anyone witness the incident?

  • Who?

  • Were statements recorded at the Nurse's station?

  • Incident Type

  • Contacted With/Contacted By

  • Reference: Complete List of all Causal Factors

    Causal Factors 2.JPG
  • Causal Factor(s)

  • Employee

  • Supervision

  • Equipment/Materials

  • Other

  • Basic Cause(s)

  • EMPLOYEE PLACEMENT - Improper matching of the affected employee's skill set to what the job or specific task demands that led to an injury or incident.

  • Immediate fix

5 Why (Root Cause)

  • 1. Why did the incident happen?

  • 2. Why did 1 happen?

  • 3. Why did 2 happen

  • 4. Why did 3 happen?

  • 5. Why did 4 happen?

Corrective Actions

  • Do the documented practices and assessments adequately cover the situation to prevent re-occurrence?

  • If no, develop a corrective action

  • Is the incident recordable and behavioral?

  • If yes, develop a corrective action

  • Is this incident a re-occurrence?

  • If yes, develop a corrective action to address the re-occurrence and learn from what did not work last time

  • Supervisor Corrective Action #1

  • Responsible Person

  • Target Date

  • Supervisor Corrective Action #2

  • Responsible Person

  • Target Date

  • Supervisor Corrective Action #3

  • Responsible Person

  • Target Date

  • Employee Signature

  • Supervisor Signature

  • Department Manager

  • ORM Manager

  • Date and time of incident

  • Describe the unsafe act

  • Add pictures of the unsafe act here:

  • Describe what was done to immediately improve, correct or respond to observation

  • Did your actions correct the observation?

  • If No, how should the observation be corrected?

  • Date and time of incident

  • Describe the unsafe condition

  • Add pictures of the unsafe condition here:

  • Describe what was done to immediately improve, correct or respond to observation

  • Did your actions correct the observation?

  • If No, how should the observation be corrected?

  • Date and time of incident

  • What was damaged (be specific)

  • Party responsible for damage

  • Name of individual(s) responsible

  • Describe in detail how the incident occurred:

  • Describe the work in progress (task) when the incident occurred

  • Information obtained during or after the incident?

  • Provide here:

  • Was plant security or a member of management notified by the 3rd party of the damage

  • File a report with local law enforcement if property was damaged and the responsible party left without notifying plant management/security. Local Police: 419-332-6464

  • Pictures of damage

  • Did anyone witness the incident?

  • Who?

  • Estimated cost of damage (needed for claim)

  • CONSULT WITH OTHER CONTRACTOR THAT MAY BE ABLE TO ASSIST WITH DETERMING COST OF DAMAGES

5 Why (Root Cause)

  • 1. Why did the incident happen?

  • 2. Why did 1 happen?

  • 3. Why did 2 happen

  • 4. Why did 3 happen?

  • 5. Why did 4 happen?

  • Date and time of incident

  • Describe the condition or act that could result in serious injury or harm

  • Add pictures here:

  • Describe what was done to immediately improve, correct or respond to observation

  • Did your actions correct the observation?

  • If No, how should the observation be corrected?

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.