Incident Investigation Report Checklist

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

• Location

• Job #:

• Date of occurrence

  Date

• Date reported

  Date

• GWR Employee?

  Yes

  No

  N/A

• Contractor?

  Yes

  No

  N/A

Type of Incident. Select all that apply.

• Near Miss?

  Off

  On

• First aid?

  Off

  On

• Medical Aid?

  Off

  On

• Restricted Work?

  Off

  On

• Lost Time Injury?

  Off

  On

• Occupational Illness?

  Off

  On

• Fire or Explosion?

  Off

  On

• Equipment Failure?

  Off

  On

• Property Damage?

  Off

  On

• Material or Business Loss

  Off

  On

• Motor Vehicle Accident

  Off

  On

• Threats?

  Off

  On

• Other

Injury

• What type of injury?

• What body part was injured?

• Was follow-up treatment required?

  Yes

  No

  N/A

Person Involved

• Employee name

• Date of Birth

• Address

• SIN#

• Health Care#

Description

• Clearly describe how the incident occurred.

Witnesses

• Include the names and phone numbers of any witnesses to the incident. Attach witness statements.

Analysis

• Immediate causes, what acts failure to act, and conditions contributed directly to this accident?

• Basic causes, what are the contributing factors? (Job factors, personal factors)

Prevention

• What action or recommendations are made to prevent recurrence? When? And action by?

Frequency Potential

• Frequent

  Off

  On

• Probable

  Off

  On

• Occasional

  Off

  On

• Remote

  Off

  On

• Improbable

  Off

  On

Severity

• Catastrophic

  Off

  On

• Critical

  Off

  On

• Moderate

  Off

  On

• Minor

  Off

  On

Costs

• Estimated:

• Actual:

Conclusion

• Extra comments

• Investigated by:

  Sign