Incident Investigation Team Report

Overview

  • Facility:

  • Date & Time of incident

  • Type of Incident

  • Specific Location of Incident

  • Mechanism of Injury

Incident Investigation

Incident Investigation

  • Person(s) Involved in the Incident

  • 1. Name of Employee Involved

  • 1. Date of Hire

  • 1. Department

  • 1. Job at time of Incident

  • 1. Time on Job

  • 2. Name of Employee Involved

  • 2. Date of Hire

  • 2. Department

  • 2. Job at time of Incident

  • 2. Time on Job

  • Description of Incident:

  • Additional Incident Facts:

  • Witness Statements:

  • Factors Contributing to the Incident:

  • Root Cause(s) of the Incident:

Recommended Corrective Action

Recommended Corrective Action:

  • First Recommended Corrective Action

  • Recommended Corrective Action:

  • Responsible Person:

  • Completion Date

  • Second Recommended Corrective Action

  • Recommended Corrective Action:

  • Responsible Person:

  • Completion Date

  • Third Recommended Corrective Action

  • Recommended Corrective Action:

  • Responsible Person:

  • Completion Date

  • Forth Recommended Corrective Action

  • Recommended Corrective Action:

  • Responsible Person:

  • Completion Date

Signatures

Signatures

  • Supervisor

  • Printed Name

  • Signature

  • Date Signed

  • Area/Operation Manager

  • Printed Name

  • Signature

  • Date Signed

  • General Manager

  • Printed Name

  • Signature

  • Date Signed

  • Safety Manager

  • Printed Name

  • Signature

  • Date Signed

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