Investigation Details
Please enter the date and time of this investigation.
What type of incident are you investigating?

Name of owner of property that was damaged?

Was the injured person an employee of Henry Bros. Co.?

Name of firms involved with the incident.

How many people were injured?
Incident Details

Name of injured

Name of persons involved at time of occurrence?

Photo of Sign- In Sheets ( If Available).
Address and location description?
What type of medical treatment was given?
When did the incident occur?
What part of the body was affected by the injury?

Give details of any tasks being carried out at the time of the incident?

Describe in detail what happened?

Incident photos

Additional facts of interest?

Inspectors signature
Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.