• Document No.

  • Short Incident Description

  • Site

  • Conducted on

  • Prepared by

  • Location
  • Investigation Team

Incident Investigation

  • Take as many photos of the scene as possible.

  • Describe, in detail, what occurred. Include the exact task being done and any relevant events leading up to the incident.

  • What type of incident occurred?

  • Date and time of incident

  • Date and time employee began work

  • Name of Injured Employee

  • Department and Shift of Injured Employee

  • Employment Status of Injured Person

  • Describe injury and parts of body affected

  • What object/substance directly injured the employee

  • Injured Employee: State in your own words description of pain/discomfort and location of injury.

  • Pain from scale 1-10

  • Was on-site first aid treatment given?

  • Who administered first aid?

  • What first aid was performed? (ice, bandage, anti-bacterial cream, etc.)

  • Is the employee requesting/in need of medical attention? Tap HERE to enter details.

  • Contact the Safety Manager immediately!

  • Was the employee transported to a local medical establishment?

  • Where was the employee taken for treatment?

  • Investigator: Give accurate description of nature and extent of injury and state your objective findings

  • Investigator: Describe the nature of the damaged equipment. What was damaged? To what extent? Is the equipment operable? Does it pose additional risk to operators in it's current state?

  • What material spilled?

  • Approximately how much material spilled?

  • Did the spill enter a local waterway?

  • Report this incident immediately to the Safety Manager!

  • Were safeguards or safety equipment provided?

  • Were safeguards or safety equipment used?

Witness Statement

  • Witness name

  • Occupation

  • Telephone number

  • Date and Time of injury

  • Location where injury occurred.

  • Describe what you saw.

  • Who or what caused the accident/injury?

  • In your opinion what body parts were injured?

  • Was there anything that could have been done to prevent injury?

  • What could have been done?

  • Did anything appear suspicious about the incident?

  • What was suspicious?

  • Witness signature

Root Cause Analysis (5 Why's)

  • Why?

  • Why
  • Question

  • Answer

  • What is the root cause of this incident?

Immediate Corrective Action

  • Enter corrective actions taken to prevent immediate reoccurrence. Enter suggestions for future corrective actions. Each "Why" in the previous section may result in a corresponding corrective action.


  • Employee signature

  • Preparers signature

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.