INCIDENT INVESTIGATION REPORT SCORECARD

• Conducted on

  Date

• Audit Title

• Select type of Incident

  Near Miss

  Incident

  Medical Aid

  Lost Time

• Facility:

• Report Number:

• Person Completing Report:

• Date of Incident:

• Time of Incident:

REPORTING

• Was incident reported within 24 hours? If Medical Aid did they complete a Short Term Accommodation form - if not lose these marks.

  Yes

  No

  N/A

• Score out of 20 points

GENERAL INFORMATION

• Did they capture the "Incident" clearly and concisely (brief description of the event)?

  Yes

  No

  N/A

• Score out of 20

PERSONAL INJURY

• Did they complete this in full?

  Yes

  No

  N/A

• Score out of 10

EVENT DESCRIPTION

• Do they list all pertinent facts leading up to the incident?

  Yes

  No

  N/A

• Score out of 20

PROPERTY DAMAGE

• Did they complete this section as applicable?

  Yes

  No

  N/A

• Score out of 5

RISK ASSESSMENT

• Did they complete this section?

  Yes

  No

  N/A

• Score out of 5

CAUSES

• Did they identify the correct direct cause?

  Yes

  No

  N/A

• Score out of 10

• Did they identify the correct indirect cause?

  Yes

  No

  N/A

• Score out of 10

ESTIMATED DAMAGE

• Estimated Facility/Property/Equipment Damage/Lost Wages

• Estimated Lost Production

• Total Loss