Investigation Report

Incident Information

Building / Site Name:

Building / Site Address:

Did this incident involve another trade?

Name of the trade company:

Worker(s) involved in the incident:


Crew Manager:

Crew Manager:


Wind Speed & Direction:

Lighting Condition:

Post Incident Drug & Alcohol Test Conducted?

Hazard Assessment Completed?

Work Activity:

Work Activity:

Incident Description

Describe Incident:

Determine the causes that likely have resulted in the incident.

Contributing Cause(s):

Root Cause(s):

Corrective Actions

What actions or recommendations are needed to prevent recurrence?




Date Implemented:
Implemented by:

Implemented by:


I hereby certify that all information is accurate and that an actual investigaton was conducted as per company policy.

Investigator's Name & Signature:
Crew Manager's Name & Signature:

Worker's Name & Signature:

Worker's Name & Signature:
Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.