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Audit

Incident Details

Name of person involved in incident

Incident investigation team

What task was being performed at the time of the incident

What happened? (e.g. 'employee tripped over box' or 'forklift hit wall')

Take photo evidence of incident
Take photo evidence of surrounding environment
Contributing Factors

Select all the relevant contributing factors for each of the categories below.
To create a corrective action click on the "Action" button, enter description of what we going to do to fix the problem, assign a due date, priority and person responsible.

Environmental factors

Description of other environmental factors

Equipment/ Materials factors

Description of other equipment/ materials factors

Work systems factors

Description of other work systems factors

People factors

Description of other work people factors

Take photo evidence of any contributing factors
Sign off
Person involved in the incident
Supervisor

Incident Investigation Template Checklist

Created by: SafetyCulture Staff | Industry: General | Downloads: 535

Use this incident investigation template to help conduct a root cause analysis following an incident or near miss at a worksite or workplace. This template can be used to help gather necessary facts and general background information of the incident.

Signup for a free iAuditor account to download and edit this checklist. It will be added to your free account and you will be able to conduct inspections from your mobile device.

Download and edit this free checklist

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Audit

Incident Details

Name of person involved in incident

Incident investigation team

What task was being performed at the time of the incident

What happened? (e.g. 'employee tripped over box' or 'forklift hit wall')

Take photo evidence of incident
Take photo evidence of surrounding environment
Contributing Factors

Select all the relevant contributing factors for each of the categories below.
To create a corrective action click on the "Action" button, enter description of what we going to do to fix the problem, assign a due date, priority and person responsible.

Environmental factors

Description of other environmental factors

Equipment/ Materials factors

Description of other equipment/ materials factors

Work systems factors

Description of other work systems factors

People factors

Description of other work people factors

Take photo evidence of any contributing factors
Sign off
Person involved in the incident
Supervisor