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Incident Report - Full Investigation & Report
Incident Report - Full Investigation & Report
SafetyCulture Staff

Incident Report - Full Investigation & Report Checklist

Collect evidence, find root causes and investigate incidents, accidents and injuries. Create a comprehensive incident investigation report. Go deeper than an early incident report template.

Use this Digital Checklist
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Free Incident Report - Full Investigation & Report Checklist

Use this Digital Checklist

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Audit

Incident Details
Date & Time of Incident
Location of Incident

Incident Severity?

Site / Project Name

Incident Type (select all that apply)
  • Hazard
  • Near-Miss
  • Slip & Fall
  • Accident
  • Injury
  • Theft
  • Fire
  • Property Damage
  • Fatality
  • Illness
  • Reportable / Notifiable
  • Loss Time
  • Other

Please describe type of incident

Name of on-duty supervisor at time of incident?

Was medical attention administered?

What kind of medical attention was administered?
  • First Aid
  • Doctor Consulted
  • Hospital
  • Ambulance
  • Medical Attention Declined

Please detail medical attention

Incident Summary

Describe what happened. Please be detailed but state only facts.

Do you wish to include a timeline of events for this incident?

Incident Timeline

Build a timeline of key incident events below

Event
Event Date / Time

Event Description

What were the weather / environmental conditions at the time of the incident?
  • Clear
  • Cloudy
  • Rain
  • Snow
  • Windy
  • Heatwave
  • Haze
  • Other

Describe the weather / environmental conditions at the time of the incident

Evidence and Attachments
Which of the following do you need to attach to this report to accuractly document this incident?
  • Evidence
  • Equipment Details
  • Vehicle Details
  • Damages
  • Other Items
Evidence Log

Please log all relevant evidence below

Evidence

Evidence Description

Evidence ID number (if applicable)

Type of evidence

Photos of evidence (if applicable)

Please detail any further information regarding this evidence (if applicable)

Vehicle Log

Please log all relevant vehicle details below

Vehicle

Vehicle Make

Vehicle Model

Vehicle Registration

Driver (if applicable)

Photos of equipment (if applicable)

Please detail any further information regarding this vehicle (if applicable)

Damage Log

Please log all relevant damage details below

Damage

Damage description

ID number (if applicable)

Photos of damage (if applicable)

Please detail any further information regarding this damage (if applicable)

Other Items Log

Please log all relevant details of other items below

Item

Item description

ID number (if applicable)

Photos of item (if applicable)

Please detail any further information regarding this item (if applicable)

Equipment Log

Please log all relevant equipment details below

Equipment

Equipment Make

Equipment Model

Equipment ID number (if applicable)

Photos of equipment (if applicable)

Please detail any further information regarding this equipment (if applicable)

People involved

Please document all people involved in this incident

Person
Person

Full Name

ID number

Contact phone number

What is this person's relation to the incident? (select all that apply)
  • Reporter of incident
  • Injured person
  • Witness
  • Primary person involved
  • Secondary Involvement
  • On-duty supervisor
  • Investigator
  • Suspect
  • Other

Describe this person's relation to the incident

Please describe this person's involvement with the incident, including all relevant information

Attach any relevant photos regarding this person

Do you want to log a statement for this person?

Statement

Statement regarding incident

Person Signature
Date & Time of Statement

Has this person sustained an injury?

Injury Details
Type of injury or illness? (select all that apply)
  • Superficial
  • Open Wound
  • Fatality
  • Concussion
  • Sprain
  • Respiratory
  • Eye Injury
  • Burns
  • Fracture
  • Electrocution
  • Fall
  • Strain
  • Dislocation
  • Struck by object
  • Entanglement
  • Assault
  • Muscle & Tendon
  • Nerve & Spinal Cord
  • Amputation
  • Intracranial
  • Other

Describe type of injury or illness

Parts of body affected? (select all that apply)
  • General Ailment
  • Head
  • Eye (Right)
  • Eye (Left)
  • Ear
  • Nose
  • Throat
  • Neck
  • Back (Upper)
  • Back (Lower)
  • Arm - Upper (Right)
  • Arm - Upper (Left)
  • Arm - Elbow (Right)
  • Arm - Elbow (Left)
  • Arm - Forearm (Right)
  • Arm - Forearm (Right)
  • Wrist (Right)
  • Wrist (Left)
  • Hand (Right)
  • Hand (Left)
  • Chest
  • Abdominal / Stomach
  • Groin / Anus
  • Leg - Upper (Right)
  • Leg - Upper (Left)
  • Leg - Knee (Right)
  • Leg - Knee (Left)
  • Leg - Lower (Right)
  • Leg - Lower (Left)
  • Ankle (Right)
  • Ankle (Left)
  • Foot (Right)
  • Foot (Left)
  • Shoulder (Left)
  • Shoulder (Right)
  • Other

Please describe injury location

Describe this injury or illness

What was the cause of this injury or illness?

Corrective Actions

Are corrective/further actions required with regard to this incident?

Please add any corrective actions to the appropriate questions above before completing this incident investigation

Have all required corrective actions been added as Actions to this inspection?

Root Cause Analysis / Contributing Factors
What were the contributing factors to this incident occurring? (select all that apply)
  • Equipment Defects
  • Unauthorized Equipment Use
  • Improper Equipment Use
  • Lack of protective safety devices
  • Employee operating at inappropriate speed
  • Equipment used outside rated capacity
  • Lack of PPE
  • Inappropriate PPE
  • Untidy Conditions (Poor Housekeeping)
  • Safety procedures not followed
  • Inadequate ventilation
  • Drugs or Alcohol

A Root Cause Analysis (RCA) is the process of determining the cause of an incident. It requires consideration of all the factors that may have contributed to this incident occurring and deeply understanding the underlying cause. One tactic to determine this is through asking "Why?" five times, to uncover the core of a problem.

Has the root cause of this issue been able to be identified?

Why is the root cause for this issue unable to be identified at this time?

How likely is this incident to reoccur in future?
  • Certain
  • Very Likely
  • Likely
  • Unlikely
  • Very Unlikely
  • Never
  • Unclear / Not Determinable

What is the root cause of this incident? Please consider and include all contributing factors

Has the root cause of this issue been rectified or eliminated?

How was the root cause rectified or eliminated?

Please attach any relevant photos or media

Please provide any relevant further details

How likely is this incident to reoccur in future?
  • Certain
  • Very Likely
  • Likely
  • Unlikely
  • Very Unlikely
  • Never
  • Unclear / Not Determinable
Sign Off

Further action/follow-up/investigation required?

Name of person/people to follow up

Name & Signature of Investigator
Incident Report - Full Investigation & Report
SafetyCulture Staff

Incident Report - Full Investigation & Report

Collect evidence, find root causes and investigate incidents, accidents and injuries. Create a comprehensive incident investigation report. Go deeper than an early incident report template.

Use this Digital Checklist
Download as PDF
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.

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