Incident Investigation Report Template

• Incident Title

General Information

• Date & time of the incident:

  Date

• Date reported:

  Date

• Reported by:

• District:

• Division:

• Work Group:

• Location of the incident:
  Address

• Equipment involved:

Serverity

• Actual Severity:

  Low

  Medium

  High

  Extreme

• Potential Severity:

  Low

  Medium

  High

  Extreme

Incident

• Category:

  Near Miss

  Incident (No Injury/No Damage)

  Injury

  Illness

  Property Damage

• Classification:

  First Aid (MI)

  Medical Treatment (MTI)

  Restricted Duty (RDI)

  Lost Time (LTI)

  Fatality

• Potential:

  Non - HPI

  HPI

  PFI
Personnel Involved

• Name:

• Job Experience:

• Time at current position:

Investigation Team

• undefined

Accident Report

• Details of Incident:

• Why did the incident happen?

  Select Poorly maintained tools or equipment Poor housekeeping, slippery floor, or tripping hazards Unguarded equipment Crowded work condition Poor storage practices Failure to wear PPE Insufficient lighting or ventilation Cold or hot temperature Improper body placement Others

  • Poorly maintained tools or equipment
  • Poor housekeeping, slippery floor, or tripping hazards
  • Unguarded equipment
  • Crowded work condition
  • Poor storage practices
  • Failure to wear PPE
  • Insufficient lighting or ventilation
  • Cold or hot temperature
  • Improper body placement
  • Others

• Please specify

• Incurred injuries

• Did the employee leave work?

  No

  Yes

• Please specify

Immediate Actions

• undefined

Data Collection (PEEPO)

• Describe Environment Conditions:

• Describe Equipment/Tool Conditions:

• Procedures:

Witness/es

• Are there any witness/es?

  Yes

  No
Witness

• Full Name

Proposed Next Steps

• Actions: