Title Page

  • Date & Time

  • Department

  • undefined

Incident Report

  • Department:

  • Date of incident:

  • Time of incident:

  • Ref. No

2. Investigation Team - Name Surname and Designation

  • Chairman: Name and Surname

  • Investigator: Name and Surname

  • H & S Rep: Name and Surname

  • Supervisor: Name and Surname

  • Injured Person: Name and Surname

  • Date of investigation

3. Type of Incident

  • Injury on Duty

  • Environmental Spill

  • Fire on Site

  • Equipment Damage

  • Occupational Disease

  • Near Miss

4. Detail description of incident (Name of affected person, part of body affected, effect on person, expected period of disablement, machine/ process involved, type of work performed if injury on duty and description of incident)

  • Description of Incident

5. Direct result/ consequences of incident on:

  • Production Hours

  • Production tons/ units

  • Man hours

  • Cost

  • Quality

  • Safety

  • Equipment

6. Root Cause Analysis Worksheet

  • Define the problem:

  • Why is it happening?

  • Why is that?

  • Why is that?

  • Why is that?

  • Why is that?

  • Unsafe condition

  • Unsafe act

7. Secondary Contributing Factors

Factors

  • Inadequate communication

  • Inadequate design of plant or equipment

  • Poor housekeeping and waste management

  • Lack/ inadequate procedure or standard

  • Unauthorised modifications/ changes

  • Lack/ inadequate warning system

  • Lack of exposure

  • Operating equipment without permission

  • Lack of supervision

  • Using equipment improperly

  • Time at work or on the job

  • Inadequate PPE

  • Length of service in section

  • Failing to follow procedure

  • Lack of focus

  • Incorrect tools used

  • Lack of skill

8. RISK RATING

  • SEVERITY/ CONSEQUENCE CRITERIA

  • LIKELIHOOD/ FREQUENCY CRITERIA:

9. Corrective/ Preventative Action

  • 1.

  • By Whom

  • Target Date:

  • 2.

  • By Whom

  • Target Date

  • 3.

  • By Whom

  • Target Date:

  • 4.

  • By Whom:

  • Target Date

  • 5.

  • By Whom

  • Target Date

10. Reportable to

  • 11. Was the incident reported to Department of Labour?

  • 12. Was the incident/ reported to Compensation Commissioner?

  • 13. Was accident/ incident reported to the Police?

  • 14. Police Station:

  • 15. Police Case number:

  • Signature of Chairman of investigation

  • Signature of Supervisor

  • Signature Chairman of H&S Committee

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  • Signature of SHE Rep

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.