Incident Investigation Report

• Client:

• Site:

• Contractor involved:

• Document No:

• Conducted on:

  Date

• Prepared by:

• Investigation team details: (Name, Surname, Position, Company):

• List of Annexture added to the investigation report:

Incident / Accident detail:

• Date and time of incident:

  Date

• Location of incident:

• Name of company/s involved:

• Injury Classification:

  Select Disable Injury Serious Injury Enviromental Near Miss Damage First aid treatment Other

  • Disable Injury
  • Serious Injury
  • Enviromental
  • Near Miss
  • Damage
  • First aid treatment
  • Other

• Specify Other:

• Description of the incident that occurred:

Employees Injured:

• Where there any injuries to employee/s on site?

  Yes

  No

• Name of employee involved:

• Permanent employee:

• Temporary employee:

• Casual employee:

• Name of Manager / Supervisor:

• Contact details of Line Manager / Supervisor:

Treatment:

• Where any treatment required to the injured employee/s?

  Yes

  No

• First Aid:

• Name and contact details of person who applied first aid:

• Provide details of treatment:

• EMS:

• Name & address of Treating Facility / Doctor:

• Provide details of treatment:

• Dr.'s Office:

• Name & address of Treating Facility / Doctor:

• Provide details of treatment:

• Hospital Stay:

• Name & address of Treating Facility / Doctor:

• Provide details of treatment:

Type of Injury:

• Type of Injury:

  Select Head Eye Neck Internal Trunk Finger Hand Arm Leg Foot Toes Other No injury to employee/s

  • Head
  • Eye
  • Neck
  • Internal
  • Trunk
  • Finger
  • Hand
  • Arm
  • Leg
  • Foot
  • Toes
  • Other
  • No injury to employee/s

• Specify Other:

Investigation questions:

• Is the permit valid. Date, time, area?

  Yes

  No

  N/A

• Did the employee sign on the permit and Rams?

  Yes

  No

  N/A

• Was the supervisor present when the incident occured?

  Yes

  No

  N/A

• Is the supervisor appointed and competant as per the safety file?

  Yes

  No

  N/A

• Employees induction still valid?

  Yes

  No

  N/A

• Employees medical valid?

  Yes

  No

  N/A

• Is the employee trained and designated (appointed) for the task being performed?

  Yes

  No

  N/A

• Were the hazards identified on the RAM;s or other documents?

  Yes

  No

  N/A

• Were barriers (signage, LOTOTO, barricade etc.) in place?

  Yes

  No

  N/A

• Where barriers adhere to?

  Yes

  No

  N/A

• Where tools and equipment inspected before use. (Proof to be added to report)?

  Yes

  No

  N/A

Effects on Employee/s:

• Effects on Employee/s:

  Select Strains Sprains Concussion Wounds Burns Fracture Poisoning Electric Shock Multiple Effect Amputation Other No effects on Employee/s

  • Strains
  • Sprains
  • Concussion
  • Wounds
  • Burns
  • Fracture
  • Poisoning
  • Electric Shock
  • Multiple Effect
  • Amputation
  • Other
  • No effects on Employee/s

• Specify Other:

• Short description of "Effect on Employee/s"

Unsafe acts (Direct Cause):

• Unsafe Acts:

  Select Machine to be off when no in use Operating at unsafe speed Making safety device inoperative Using unsafe equipment Using equipment unsafely Unsafe loading, placing, mixing Taking unsafe position Working on moving / unsafe equipment Failure to use PPE Distracting, teasing, horsplay Not using PPE Not using PPE correctly Negligence Other Not Applicable

  • Machine to be off when no in use
  • Operating at unsafe speed
  • Making safety device inoperative
  • Using unsafe equipment
  • Using equipment unsafely
  • Unsafe loading, placing, mixing
  • Taking unsafe position
  • Working on moving / unsafe equipment
  • Failure to use PPE
  • Distracting, teasing, horsplay
  • Not using PPE
  • Not using PPE correctly
  • Negligence
  • Other
  • Not Applicable

• Short description of "unsafe act":

• Short description of "unsafe act"

Personal factors (Basic Cause):

• Personal factors:

  Select Lack of knowledge or skill Physical or mental Improper attitude or motivation Other Not Applicable

  • Lack of knowledge or skill
  • Physical or mental
  • Improper attitude or motivation
  • Other
  • Not Applicable

• Specify Other:

• Short discription of "personal factors"

Unsafe Conditions (Direct Cause):

• Unsafe Conditions:

  Select Unguarded Defective tools or equipment Hazardous arrangement Unsafe design or construction Poor lighting Poor floor condition Poor ventilation Unsafe Scaffold Heat or cold stress factor Poor or unsafe structure Unsafe ladder Other Not Applicable

  • Unguarded
  • Defective tools or equipment
  • Hazardous arrangement
  • Unsafe design or construction
  • Poor lighting
  • Poor floor condition
  • Poor ventilation
  • Unsafe Scaffold
  • Heat or cold stress factor
  • Poor or unsafe structure
  • Unsafe ladder
  • Other
  • Not Applicable

• Specify Other:

• Short description of "unsafe conditions"

• Short description of unsafe conditions

Job Factors (Basic Cause):

• Job Factors:

  Select Inadequate work standards Unsafe conditions Other Not Applicable

  • Inadequate work standards
  • Unsafe conditions
  • Other
  • Not Applicable

• Specify Other:

• Short description of "job factors":

Whiteness statement:

• Summary of whiteness statements attached: (Name, Surname, Position, company name):

Steps taken at the time to remedy the situation:

• Indicate steps taken when the incident occured:

Corrective Action:

• Describe action taken to prevent injury from happening again:

Root Cause:

• Was the root cause identified?

  Yes

  No

• undefined

Findings and Recommendations:

• Any additional findings or recommendations ?

  Yes

  No

• Findings:

• Would you like to add additional photos?

  Media

• Recommendations:

• Would you like to add additional photos?

  Media

Sign off of incident report:

• Investigator:

  Sign

• Contractors 16.2:

  Sign

• Contractors CR8.1:

  Sign

• Contractors OHS 17.1 or CR8.5:

  Sign