Incident Investigation Report

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

• Name of person involved in Incident

• Job Title

• Experience

• Supervisor

• Date and Time of Incident

  Date

• Jobsite Name & Address

• Specific Jobsite Location

• Who was the Incident Reported to

• Date Reported

  Date

• Type of Report

  Select Report Only First Aid Medical Aid Modified Work Loss Time Other

  • Report Only
  • First Aid
  • Medical Aid
  • Modified Work
  • Loss Time
  • Other

• Nature of Injury

• Description of Damage

• Describe accident

• What went Wrong

• Corrective Action(Something must change in order to prevent recurrence)

• Witness Name

• Witness statement

• Any Pictures if Required

  Media

• Injury Cause

  Select Compressed/Pinched Cut Fall Against Object Struck by Object Exposure to Environment Driving Rough Machinery Exposure to Chemical Foreign object entering Caught in Moving Equipment Overexertion-Pushing/Pulling Tool/Equipment Malfunction Electrocution Fall from Height Overexertion-Lifting Slip Trip Rubbing or Abrasion Other/Unknown

  • Compressed/Pinched
  • Cut
  • Fall Against Object
  • Struck by Object
  • Exposure to Environment
  • Driving Rough Machinery
  • Exposure to Chemical
  • Foreign object entering
  • Caught in Moving Equipment
  • Overexertion-Pushing/Pulling
  • Tool/Equipment Malfunction
  • Electrocution
  • Fall from Height
  • Overexertion-Lifting
  • Slip
  • Trip
  • Rubbing or Abrasion
  • Other/Unknown

• Injury Location

  Select Upper Arm Left Upper Arm Right Lower Arm Left Lower Arm Right Hands/Fingers Ribs & Chest Abdominal Area Lower Back Upper Back Upper Leg Left Upper Leg Right Lower Leg Left Lower Leg Right Foot/Toes Left Foot/Toes Right Multiple Injuries Shoulder Right Shoulder Left Face Area Eye Ear Head

  • Upper Arm Left
  • Upper Arm Right
  • Lower Arm Left
  • Lower Arm Right
  • Hands/Fingers
  • Ribs & Chest
  • Abdominal Area
  • Lower Back
  • Upper Back
  • Upper Leg Left
  • Upper Leg Right
  • Lower Leg Left
  • Lower Leg Right
  • Foot/Toes Left
  • Foot/Toes Right
  • Multiple Injuries
  • Shoulder Right
  • Shoulder Left
  • Face Area
  • Eye
  • Ear
  • Head

WHAT FACTORS CONTRIBUTED TO THIS EVENT

• Was Appropriate Equipment Used

  Select Yes No

  • Yes
  • No

• Was Equipment in Good Working Order

  Select Yes No

  • Yes
  • No

• Was Prevention Reasonably Practicable

  Select Yes No

  • Yes
  • No

• Were Correct Procedures Followed

  Select Yes No

  • Yes
  • No

• Was the Worker Trained in the Assigned Task

  Select Yes No

  • Yes
  • No

• Was the Required PPE in Use

  Select Yes No

  • Yes
  • No

• Where Judgment, Health or Ability Impaired for any Reason

  Select Yes No

  • Yes
  • No

• Additional Comments

• Worker Involved

  Sign

• Supervisor

  Sign

• Safety Representative

  Sign

SENIOR MANAGEMENT REVIEW

• Further Action/Recommendation/Comments

• Follow Up

  Select No Further Action Required For Further Consideration Further Action Necessary

  • No Further Action Required
  • For Further Consideration
  • Further Action Necessary

• Management

  Sign