Incident Investigation / Rev.New

• Incident No.

• Audit Title

• Client / Job Number

• Conducted on

  Date

• Prepared by

GENERAL INFORMATION ABOUT THE INVESTIGATION

• Date investigation opened

  Date

• Were the Police notified or on-site?

  Yes

  No

  N/A

• Name / Phone Number / Agency

• Explain: (be as specific as possible).

• Investigated by:
  (includes other employers)

investigator

• Name / Phone Number / Company

• Date investigation closed

  Date

GENERAL INFORMATION ABOUT THE PROJECT

• Project Title

• Project Manager / Phone Number

• Project General Foreman / Phone Number

• Project Site Foreman / Phone Number

GENERAL INFORMATION ABOUT THE INCIDENT

• Date and time of incident (if known)

  Date
• Address / Location
  Address

• Road Type

  Select Freeway/Express Way (60-70mph) Rural Highway (50-60mph) Rural Road (40-50 mph) Rural Road/Urban Arterial (35-40 mph) Rural Road/Urban Street/Residential-Business (25-35 mph) Urban Street/Residential Neighborhood (<25 mph)

  • Freeway/Express Way (60-70mph)
  • Rural Highway (50-60mph)
  • Rural Road (40-50 mph)
  • Rural Road/Urban Arterial (35-40 mph)
  • Rural Road/Urban Street/Residential-Business (25-35 mph)
  • Urban Street/Residential Neighborhood (<25 mph)

• Traffic Volume

  Low Volume (<5 vehicles/min/lane)

  Moderate Volume (~12 vehicles/min/lane)

  High Volume (>20 vehicles/min/lane)

  Very High Volume (Beyond advanced warning area)

• Incident Site

  Advanced Warning Area

  Transition Area

  Activity Area

  Termination Area

• Briefly describe the incident.

• Photographs of Incident Site

  Media

• Did the incident result in any of the following? (check all that apply)

  Select Fatality Serious injury Non-Serious injury Property damage Near miss

  • Fatality
  • Serious injury
  • Non-Serious injury
  • Property damage
  • Near miss

VICTIM AND WITNESS STATEMENTS

• Statements

Victim or Witness

• This person is a

  Victim

  Witness

  Other

• Name / Phone Number / Company

• Their Statement:

• Signature

  Sign

• Was this person physically injured?

  Yes

  No

  Unknown

• Describe the injuries. Be as specific as possible.

• Did this person receive medical treatment beyond basic first aid?

  Yes

  No

  Unknown

• Hospital/Clinic/Physician

• Does this person's account of the incident support the victim's account?

  Yes

  No

  Partially

  Unknown

• Explain: (be as specific as possible).

EXTENT OF DAMAGE

• Was there any damage?

  Yes

  No

  Unknown

• What was damaged? (be as specific as possible)

Item

• Description of item damaged. (Property or vehicle make/model/color/plate number)

• Photographs of damage.

  Media

INCIDENT ANALYSIS

• Was a police report, warning or citation issued?

  Yes

  No

  Unknown

• Explain: (be as specific as possible).

• Incident Cause

Cause

• Were conditions unsafe at time of incident? (physical, environmental, mechanical)

  Yes

  No

  Unknown

• Explain: (be as specific as possible).

• Was an unsafe/at-risk behavior or action a factor in the incident?

  Yes

  No

  Unknown

• Explain: (be as specific as possible).

• Is there a specific safety rule or regulation that was violated?

  Yes

  No

  Unknown

• Describe: (be as specific as possible).

• Has disciplinary action been taken? Describe.

• Immediate action required?

  Yes

  No

  Unknown

• When should this action be completed

  Date

• Who is responsible to oversee this action?

• Long term action required?

  Yes

  No

  Unknown

• When should this action be completed

  Date

• Who is responsible to oversee this action?

FOLLOW-UP INVESTIGATION

• Is a follow-up investigation required?

  Yes

  No

  Unknown

• Who is responsible to oversee this action?

• Follow-up investigation completed on

  Date

SUBROGATION

• Are there opportunities for subrogation in this case?
Subrogation opportunity

• Name/Company

• Reason/justification

• Has all physical evidence been secured, photographed, or otherwise preserved?