Information

  • Division Where Incident Occurred:

  • Address / Location of Incident:

  • Did an Injury Occur?

  • Date / Time of Incident:

  • Members of the Investigation Team:

Part 1 : Particulars

  • Did the incident involve injury?

  • Name of Injured Worker:

  • Injured Worker's Occupation / Job Title:

  • Nature of Injury:

  • Supervisor's Name:

  • Did the incident involve property damage?

  • Describe the nature of the property damage:

  • Was first aid rendered?

  • If yes, by whom? (If outside emergency assistance was required, provide details)

Part 2 : Description of Incident

  • Describe the incident in detail:

Part 3 : Evidence

  • Sketch of the Incident Scene:

  • Describe the physical evidence collected:

  • List and Describe the photos and videos:

  • Photo / Video Evidence:

  • Were there any witnesses to this incident?

  • Witness Name:

  • Contact information for witness if he / she is not an employee of Kroeker Farms Limited

  • Occupation:

  • Date of the Interview:

  • Name of Interviewer:

  • Summary of Witness' Statement:

  • Signature of Witness: I hereby state that the above summary is an accurate and complete statement of what I saw take place.

  • Witness Name:

  • Contact information for witness if he / she is not an employee of Kroeker Farms Limited

  • Occupation:

  • Date of Interview:

  • Name of Interviewer:

  • Summary of Witness' Statement:

  • Signature of Witness: I hereby state that the above summary is an accurate and complete statement of what I saw take place.

Part 4 : Incident Causation

  • What was the DIRECT CAUSE of the incident? (What caused injury or damage?)

  • What was the INDIRECT CAUSES? (What caused the incident?)

  • TASK:

  • WORKER(S):

  • MATERIAL / EQUIPMENT:

  • MANAGEMENT:

  • ENVIRONMENT:

Part 5 : Corrective Acrion

  • Immediate corrective actions to prevent recurrence:

  • Target Date for completion of Corrective Action:

  • Long term solutions:

  • Target Date for Long Term Solutions:

Report Review:

  • Signature of Investigator:

  • Signature of Investigator:

  • Signature of Investigator:

  • Date Report Completed:

  • Distribute Report to:

  • Signature of Safety Committee Employer Co-Chair:

  • Signature of Safety Committee Worker Co-Chair:

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.