Incident Report - Full Investigation & Report Checklist

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

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?