Incident Investigation Report

• Conducted on

  Date

• Prepared by

• Location
  Address

• Injured person

• Date/Time

  Date
• Location
  Address

• Contact name

• Staff/Contractor:

• Department:

• Incident Severity Rating:

• Lead Investigator:

• Investigation Participants:

• Has this incident happened before? <br>

  YES

  NO

• Were procedures followed?

  YES

  NO

• Was the person trained?

  YES

  NO

• Drug/Alcohol test completed?

  YES

  NO

• Test results

  Negative

  Positive

• Eye witness

  YES

  NO

• Eye witness name

• Type of incident

  Select Close call Equipment damage Injury sustained Motor vehicle Non-work related Property damage Public liability / reputation Regulatory Service quality Vehicle incident

  • Close call
  • Equipment damage
  • Injury sustained
  • Motor vehicle
  • Non-work related
  • Property damage
  • Public liability / reputation
  • Regulatory
  • Service quality
  • Vehicle incident

• Event outline

• Immediate corrective action

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

• Tick appropriate box(s)

  People (human factors involved)

  Places (immediate work environment and surrounds

  Plant (equipment, tools, facilities, materials, substances)

  Procedures (organisational and system issues)

  Protection (barriers and safeguards)

• 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

  Date

• Signature

  Sign

Manager sign off and actions completed

• Name

• Date/Time

  Date

• Signature

  Sign