Incident Investigation Report - November 2013

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

• Location

• Job #:

• Date of occurrence

  Date

• Date reported

  Date

• GWR Employee?

  Yes

  No

  N/A

• Contractor?

  Yes

  No

  N/A

Type of Incident. Select all that apply.

• Near Miss?

  Yes

  No

  N/A

• First Aid?

  Yes

  No

  N/A

• Medical Aid?

  Yes

  No

  N/A

• Restricted Work?

  Yes

  No

  N/A

• Lost Time Injury?

  Yes

  No

  N/A

• Occupational Illness?

  Yes

  No

  N/A

• Fire / Explosion?

  Yes

  No

  N/A

• Equipment Failure?

  Yes

  No

  N/A

• Property Damage?

  Yes

  No

  N/A

• Material or Business Loss?

  Yes

  No

  N/A

• Motor Vehicle Accident?

  Yes

  No

  N/A

• Threats?

  Yes

  No

  N/A

• Other

Injury

• What type of injury?

• What body part was injured?

• Was follow-up treatment required?

  Yes

  No

  N/A

Person Involved

• Employee name

• Date of Birth

• Address

• SIN#

• Health Care#

Description

• Clearly describe how the incident occurred.

• Add media

  Media

Witnesses

• Include the names and phone numbers of any witnesses to the incident. Attach witness statements.

Analysis

• Immediate causes, what acts failure to act, and conditions contributed directly to this accident?

• Basic causes, what are the contributing factors? (Job factors, personal factors)

Prevention

• What action or recommendations are made to prevent recurrence? When? And action by?

Frequency Potential and Severity

• Frequency Potential

  Frequent

  Probable

  Occasional

  Remote

  Improbable

• Severity

  Catastrophic

  Critical

  Moderate

  Minor

Costs

• Estimated:

• Actual:

Conclusion

• Extra comments

• Investigated by:

  Sign