Incident Investigation

• Site conducted

  Select

• Conducted on

  Date

• Prepared by

• Location
  Address

• Incident Date:

  Date

• Department/Area:

• Type of Incident:

  Injury

  Near Miss

  Property Damage

  Environmental Impact

  Security Breach

• Name of Injured Person:

• Nature of Injuries

• Incident Description:

• Reported By:

• Job Title:

• Contact Information:

• Witnesses:

  Yes

  No

• Witness Name:

• Witness Contact Information:

• First Aid/Treatment Provided:

  Yes

  No

• Treatment Deatils:

• Hospital Treatment required:

  Yes

  No

• Description of Damage:

• Estimated Cost:

• Description of Impact:

• Measures Taken To Control:

Actions Taken To Secure The Area:

• Was Emergency Response Activated:

  Yes

  No

• Description of Response:

• Equipment or Machinery Involved:

  Yes

  No

• Type of Equipment:

• Was the Equipment Operating Properly:

  Yes

  No

• Describe the Issues

Possible Causes:

• Check all that apply:

  Select Human Error Equipment Failure Environmental Conditions Inadequate Training Poor Communication Lack of Proper Safety Equipment No Process

  • Human Error
  • Equipment Failure
  • Environmental Conditions
  • Inadequate Training
  • Poor Communication
  • Lack of Proper Safety Equipment
  • No Process

• Were Safety Procedures/Protocols Followed:

  Yes

  No

• If No Explain:

• Were There Any Warning Signs:

  Yes

  No

• If Yes Describe:

• Root Cause:

• Additional Contributing Causes:

Corrective Actions:

• Immediate Corrective Actions:

• Long-Term Corrective Actions:

• Responsible Parties:

• Timeline for Closure: