Incident Investigation Team Report

• Conducted on

  Date

• Prepared by

• Location
  Address

Overview

• Facility:

• Date & Time of incident

  Date

• Type of Incident

  Select Injury Illness Lost Time Restricted/Transfer Recordable First Aid Near Miss Property Damage Environmental

  • Injury
  • Illness
  • Lost Time
  • Restricted/Transfer
  • Recordable
  • First Aid
  • Near Miss
  • Property Damage
  • Environmental

• Specific Location of Incident

• Mechanism of Injury

Incident Investigation

• Person(s) Involved in the Incident

• 1. Name of Employee Involved

• 1. Date of Hire

  Date

• 1. Department

• 1. Job at time of Incident

• 1. Time on Job

• 2. Name of Employee Involved

• 2. Date of Hire

  Date

• 2. Department

• 2. Job at time of Incident

• 2. Time on Job

• Description of Incident:

• Additional Incident Facts:

  Media

• Witness Statements:

• Factors Contributing to the Incident:

• Root Cause(s) of the Incident:

Recommended Corrective Action:

• First Recommended Corrective Action

• Recommended Corrective Action:

• Responsible Person:

• Completion Date

  Date

• Second Recommended Corrective Action

• Recommended Corrective Action:

• Responsible Person:

• Completion Date

  Date

• Third Recommended Corrective Action

• Recommended Corrective Action:

• Responsible Person:

• Completion Date

  Date

• Forth Recommended Corrective Action

• Recommended Corrective Action:

• Responsible Person:

• Completion Date

  Date

Signatures

• Supervisor

• Printed Name

• Signature

  Sign

• Date Signed

  Date

• Area/Operation Manager

• Printed Name

• Signature

  Sign

• Date Signed

  Date

• General Manager

• Printed Name

• Signature

  Sign

• Date Signed

  Date

• Safety Manager

• Printed Name

• Signature

  Sign

• Date Signed

  Date