Incident Investigation

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Details of the incident/near miss

• Provide a short description of the incident/near miss:

• Date and time of the incident/near miss:

  Date

• Location where the incident occured:

• Add media

  Media

• Was anyone injured

  Yes

  No

  N/A

• Describe the nature of the injury/s

• Name of injured person/s

• What activity was being conducted a the time of the incident:

• What happened leading up to the event, what was the injured employee doing, was there any equipment or tools being used:

• Describe in detail how the event happened:

• Does the organisation have relevant training or procedures in place to prevent this type of event from happening:

  Yes

  No

  N/A

• Has the employee been trained in the procedure, has the procedure followed:

• Are there any witnesses to the event

  Yes

  No

  N/A

• Name of witness

Add witness

• Analysis of the event:

• Recommendations: