Investigator
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Site conducted
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Conducted on
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Prepared by
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Location
Investigation Report
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Incident Date:
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Department/Area:
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Incident Description:
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Type of Incident:
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Name of Injured Person:
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Nature of Injuries
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Reported By:
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Job Title:
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Contact Information:
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Witnesses:
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Witness Name:
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Witness Contact Information:
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First Aid/Treatment Provided:
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Treatment Deatils:
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Hospital Treatment required:
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Description of Damage:
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Estimated Cost:
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Description of Impact:
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Measures Taken To Control:
Actions Taken To Secure The Area:
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Was Emergency Response Activated:
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Description of Response:
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Equipment or Machinery Involved:
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Type of Equipment:
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Was the Equipment Operating Properly:
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Describe the Issues
Possible Causes:
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Check all that apply:
- Human Error
- Equipment Failure
- Environmental Conditions
- Inadequate Training
- Poor Communication
- Lack of Proper Safety Equipment
- No Process
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Were Safety Procedures/Protocols Followed:
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If No Explain:
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Were There Any Warning Signs:
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If Yes Describe:
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Root Cause:
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Additional Contributing Causes:
Corrective Actions:
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Immediate Corrective Actions:
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Long-Term Corrective Actions:
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Responsible Parties:
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Timeline for Closure: