Incident Investigation Template

• Conducted on

  Date

• Prepared by

• Location
  Address

Incident Details

• Name of Person Involved with the incident:

• Job Title:

• Department:

• Years Experience:

  0-2 Years

  2-5 Years

  5-10 Years

  10 Years +

• Date of Incident:

  Date

• Time of Incident:

  Date

• Date Incident was reported:

  Date

• Location of the incident/injury:

• Names of witness(es):

• On Site Treatment provided?

  None

  First Aid

  Medical

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

Incident/Injury Classification

• Injury resulted in lost time or workers compensation with lost days

• Injury resulted without any lost time or workers compensation without any lost time.

• First Aid

• Incident (Property damage etc)

• Near Miss

• Loss Of Containment (Spillage)

• Non Industrial

Incident/Injury Description

• How did the incident/injury occur and what part of the body was injured? (Please describe in detail).

• Photo of incident location:

  Media

Type of Incident/Injury

• Laceration

• Slips/Trips/Falls (All Levels)

• Struck by moving (and or flying/falling object)

• Redness/Swelling of the eye

• Contact with electricity or electrical discharge

• Repetitive Motion

• Manual Handling (Lifting/carrying etc)

• Muscle/Tendon Tear

• Sprain/Strain

• Dermatitis

• Exposure to fumes

• Contusion

• Burn

• Fracture

• Other

Witness Statements:

• Please provide statements from any/all witnesses present:

• Witness (1) Name:

  Sign

• Witness (1) Statement:

• Witness (2) Name:

  Sign

• Witness (2) Statement:

• Witness (3) Name:

  Sign

• Witness (3) Statement:

• Witness (4) Name:

  Sign

• Witness (4) Statement:

Injured Person Statement:

• Name:

  Sign

• Statement:

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

• Photo's/Videos' to support environmental factors:

  Media

• Equipment/ Materials factors

  Select Equipment Materials Tools Mobile Plant

  • Equipment
  • Materials
  • Tools
  • Mobile Plant

• Description of Equipment/Materials factors

• Photos'/Video's to support Equipment/material factors:

  Media

• 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/Unfamiliar Task Distraction/personal issues/stress Lack of or Poor Communication Other PPE not worn correctly

  • Procedure not followed/no procedure exists
  • Drugs/alcohol
  • Fatigue
  • Time/Production pressures
  • Change of routine/Unfamiliar Task
  • Distraction/personal issues/stress
  • Lack of or Poor Communication
  • Other
  • PPE not worn correctly

• Description of other work people factors

Incident/Injury Direct Cause

• Please select the following that is believed to be the cause of the incident/injury:

  Select Allergic reaction (PPE, SOP's followed) Equipment Failure Improper Ergonomics Improper use of equipment Lack of or improper use of PPE Driver Error (FLT as an example) Failure to follow SOP's Improper handling of hazardous materials Negligence Not authorised/trained to operate equipment Poor Housekeeping Unapproved altering of tools/machinery

  • Allergic reaction (PPE, SOP's followed)
  • Equipment Failure
  • Improper Ergonomics
  • Improper use of equipment
  • Lack of or improper use of PPE
  • Driver Error (FLT as an example)
  • Failure to follow SOP's
  • Improper handling of hazardous materials
  • Negligence
  • Not authorised/trained to operate equipment
  • Poor Housekeeping
  • Unapproved altering of tools/machinery

• Please give a brief explanation of the causes of the incident/injury:

Action Plan

• Please specify any immediate actions taken to prevent reoccurrence and/or any short/long term actions required. Also include the person responsible for each action and a proposed date for this to be completed:

• Action Plan detail:

• Investigation Completed by:

  Sign

• Supervisor Signature:

  Sign

• EHS Department Signature:

  Sign

Sign off

• Person involved in the incident

  Sign

• Supervisor

  Sign