Title Page
Incident Investigation
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Conducted on:
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Incident Type:
- Near Miss
- Property / Equipment Damage
- Injury
- Lost Equipment
- Vehicle Accident
- Environmental
- Other
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Type of Injury:
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Incident Reported to:
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Incident Reported by:
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Incident Reported on:
Risk Classification
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Incident Risk Classification:
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"A" or "High" - Potential for major injury, illness, fatality (Imminent danger exists). Situation must be corrected immediately.
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"B" or "Medium" - Possibility for serious injury, illness, property/equipment damage.
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"C" or "Low" - Minor potential for injury, illness, equipment damage (results would not be expected to be serious).
Investigation Report
Incident Information
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Building / Site Name:
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Building / Site Address:
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Did this incident involve another trade?
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Name of the trade company:
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Worker(s) involved in the incident:
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Worker(s):
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Crew Manager:
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Crew Manager:
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Weather:
- Clear
- Overcast
- Rain
- Snow
- Foggy
- N/A
Temperature:
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Wind Speed & Direction:
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Lighting Condition:
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Post Incident Drug & Alcohol Test Conducted?
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Hazard Assessment Completed?
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Work Activity:
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Work Activity:
Incident Description
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Describe Incident:
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Determine the causes that likely have resulted in the incident.
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Contributing Cause(s):
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Root Cause(s):
Corrective Actions
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What actions or recommendations are needed to prevent recurrence?
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Recommendations:
Receommendation
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Recommendation:
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Date Implemented:
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Implemented by:
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Implemented by:
Signatures
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I hereby certify that all information is accurate and that an actual investigaton was conducted as per company policy.
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Investigator's Name & Signature:
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Crew Manager's Name & Signature:
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Worker's Name & Signature:
Worker
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Worker's Name & Signature:
