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:

  • Worker(s):

  • Crew Manager:

  • Crew Manager:

  • Weather:

  • Temperature:
  • 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?

  • Recommendations:

  • Receommendation
  • Recommendation:

  • Date Implemented:

  • Implemented by:

  • Implemented by:

Signatures

  • 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
  • Worker's Name & Signature:

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