Incident Investigation Report

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Investigation Status:

  Pending

  Completed

• Prepared by

• Location
  Address

• Personnel

Date & Time The Incident Occurred Or Was Discovered

• Date & Time The Incident Occurred /Discovered:

  Date

• Date & Time Reported:

  Date

• Location Of the Incident:

• Coordinates:
  Address

Incident Classification

• Information Report / Non-Work Related

• Near Miss

• Spill / Release

• Property Damage

• Illness

• Injury:

• Injury Classification:

  Minor First Aid

  First Aid

  Recordable

  Restricted Duty

  Lost Time

Employee Information

• Employee's Full Name:

• Employee ID Number:

• Employee Gender:

  Male

  Female

• Employee's Date Of Birth:

  Date

• Short Service Employee?

  Yes

  No

• Employee's Phone Number:

• Injury / Illness?

• Describe the location and nature of the injury.

• Describe Treatment.

Property Damage

• Property Owner's Information:

• Description of property and damage:

Utility Damage

• Type of Utility:

  Select Electrical Line Telephone Line Television Cable Fiber Optic Line Pipeline (Gas/Oil) Water Line Sewer Line Other

  • Electrical Line
  • Telephone Line
  • Television Cable
  • Fiber Optic Line
  • Pipeline (Gas/Oil)
  • Water Line
  • Sewer Line
  • Other

• Utility Owner:

• Cable / Line Size:

• Were Locates Requested?

  Yes

  No

  N/A

• One-Call Ticket Number:

• Was The Utility Located?

  Yes

  No

  N/A

• Were The Locates Correct?

  Yes

  No

  N/A

Description Of Events

• Brief Description Of Incident:

• Additional Investigation Information:

• Causes Or Factors:

• Prevention Measures:

• Attach Photos:

  Media

• Photo Notes:

• Diagrams:

  Drawing