Incident Investigation

• Site conducted

  Select

• Conducted on

  Date

• Incident Date

  Date
• Location
  Address

• Prepared by

• Department Site Personnel

Incident Details

• Name of person involved in incident

• What task was being performed at the time of the incident

• Type of Incident:

  First Aid

  Medical Treatment

• Type of Injury:

• Affected Extremity:

• Incident Summary:

• Photo evidence of incident

  Media

• Photo evidence of surrounding environment

  Media

Contributing Factors

• Select all the relevant contributing factors for each of the categories below.
  To create a corrective action click on the "Action" button, enter description of what we going to do to fix the problem, assign a due date, priority and person responsible.

• Environmental factors

  Select Noise Lighting Vibration Damaged/ unstable floor Layout/ design Dust/ fume Slip/ trip hazard Other

  • Noise
  • Lighting
  • Vibration
  • Damaged/ unstable floor
  • Layout/ design
  • Dust/ fume
  • Slip/ trip hazard
  • Other

• Description of other environmental factors

• Equipment/ Materials factors

  Select Wrong equipment for the job Equipment failure Inadequate maintenance Material/ equipment too heavy/ awkward Inadequate guarding Inadequate training provided Other

  • Wrong equipment for the job
  • Equipment failure
  • Inadequate maintenance
  • Material/ equipment too heavy/ awkward
  • Inadequate guarding
  • Inadequate training provided
  • Other

• Description of other equipment/ materials factors

• Work systems factors

  Select Hazard not identified No/ inadequate risk assessment conducted No/ inadequate safe work procedure No/ inadequate controls implemented Hazard not reported Inadequate training/ supervision Other

  • Hazard not identified
  • No/ inadequate risk assessment conducted
  • No/ inadequate safe work procedure
  • No/ inadequate controls implemented
  • Hazard not reported
  • Inadequate training/ supervision
  • Other

• People factors

  Select Procedure not followed/ no procedure exists Drugs/ alcohol Fatigue Time/ production pressures Change of routine Distraction/ personal issues/ stress Lack of communication Other

  • Procedure not followed/ no procedure exists
  • Drugs/ alcohol
  • Fatigue
  • Time/ production pressures
  • Change of routine
  • Distraction/ personal issues/ stress
  • Lack of communication
  • Other

Determination

• Preventable:

  Yes

  No

Prevention

• Action Plan:

• Responsibility:

• Target Date For Completion:

  Date

• Action Plan:

• Responsibility:

• Target Date For Completion:

  Date

• Action Plan:

• Responsibility:

• Target Date For Completion:

  Date

• Action Plan:

• Responsibility:

• Target Date For Completion:

  Date

Signatures

• Person involved in the incident

  Sign

• Supervisor

  Sign

• Facilities Loss Control Officer

  Sign