Title Page

  • Conducted on

  • Prepared by

  • Location

Incident Details

  • Name of person involved in incident

  • Incident investigation team

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

  • What happened? (e.g. 'employee tripped over box' or 'forklift hit wall')

  • Take photo evidence of incident

  • Take photo evidence of surrounding environment

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

  • Description of other environmental factors

  • Equipment/ Materials factors

  • Description of other equipment/ materials factors

  • Work systems factors

  • Description of other work systems factors

  • People factors

  • Description of other work people factors

  • Take photo evidence of any contributing factors

Sign off

  • Person involved in the incident

  • Supervisor

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.