Incident Investigation

• Conducted on

  Date
• Location
  Address

Incident Details

• Name of person involved in incident

• Incident investigation team

• Type of incident / Accident

  Near miss

  Minor (First Aid)

  Lost time

  Major ( Severe)

  Equipment Damage

• 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 surrounding environment

  Media

Injury details

• What body part was injured

  Select Head Neck Back Arms Legs Face Hands Feet

  • Head
  • Neck
  • Back
  • Arms
  • Legs
  • Face
  • Hands
  • Feet

• Nature of Injury

  Select Cut (laceration) Bruise Sprain Amputation Concussion Puncture Burn Broken bone / s

  • Cut (laceration)
  • Bruise
  • Sprain
  • Amputation
  • Concussion
  • Puncture
  • Burn
  • Broken bone / s

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

  Select Noise Lighting Vibration Damaged/ unstable floor Layout/ design Dust/ fume Slip/ trip hazard Other

  • Noise
  • Lighting
  • Vibration
  • Damaged/ unstable floor
  • Layout/ design
  • Dust/ fume
  • Slip/ trip hazard
  • Other

• Description of other environmental factors

• Equipment/ Materials factors

  Select Wrong equipment for the job Equipment failure Inadequate maintenance Material/ equipment too heavy/ awkward Inadequate guarding Inadequate training provided Other

  • Wrong equipment for the job
  • Equipment failure
  • Inadequate maintenance
  • Material/ equipment too heavy/ awkward
  • Inadequate guarding
  • Inadequate training provided
  • Other

• Description of other equipment/ materials factors

• Work systems factors

  Select Hazard not identified No/ inadequate risk assessment conducted No/ inadequate safe work procedure No/ inadequate controls implemented Hazard not reported Inadequate training/ supervision Other

  • Hazard not identified
  • No/ inadequate risk assessment conducted
  • No/ inadequate safe work procedure
  • No/ inadequate controls implemented
  • Hazard not reported
  • Inadequate training/ supervision
  • Other

• Description of other work systems factors

• People factors

  Select Procedure not followed/ no procedure exists Drugs/ alcohol Fatigue Time/ production pressures Change of routine Distraction/ personal issues/ stress Lack of communication Other

  • Procedure not followed/ no procedure exists
  • Drugs/ alcohol
  • Fatigue
  • Time/ production pressures
  • Change of routine
  • Distraction/ personal issues/ stress
  • Lack of communication
  • Other

• Description of other work people factors

• Take photo evidence of any contributing factors

  Media

Corrective actions

• Please write corrective actions

• Give due date for corrective actions

  Date

Sign off

• Person involved in the incident

  Sign

• Supervisor

  Sign