• Injured person

  • Date/Time

  • Location
  • Contact name

  • Staff/Contractor:

  • Department:

  • Incident Severity Rating:

  • Lead Investigator:

  • Investigation Participants:

  • Has this incident happened before?

  • Were procedures followed?

  • Was the person trained?

  • Drug/Alcohol test completed?

  • Test results

  • Eye witness

  • Eye witness name

  • Type of incident

  • Event outline

  • Immediate corrective action

Report

  • The 5 P’s - Refer to the 5 P’s for contributing factors and the Root Cause.

  • Tick appropriate box(s)

  • Event Findings (Unsafe practices or conditions that helped lead to the primary cause of the incident)

  • Root Cause (The underlying reason(s) for this incident, 5 Whys?)

  • Recommendations

  • Corrective Actions (Steps to insure incident does not happen again based on the Contributing factors/Root Causes)

Report completed and investigated by

  • Name

  • Date/Time

  • Signature

Manager sign off and actions completed

  • Name

  • Date/Time

  • Signature

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