Title Page
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Document No.
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Audit Title
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Client / Site / Project
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Investigation conducted on
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Prepared by
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Location
Incident Details
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Date & Time of Incident
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Location of Incident
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Incident Severity?
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Site / Project Name
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Incident Type (select all that apply)
- Hazard
- Near-Miss
- Slip & Fall
- Accident
- Injury
- Theft
- Fire
- Property Damage
- Fatality
- Illness
- Reportable / Notifiable
- Loss Time
- Other
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Please describe type of incident
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Name of on-duty supervisor at time of incident?
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Was medical attention administered?
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What kind of medical attention was administered?
- First Aid
- Doctor Consulted
- Hospital
- Ambulance
- Medical Attention Declined
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Please detail medical attention
Incident Summary
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Describe what happened. Please be detailed but state only facts.
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Do you wish to include a timeline of events for this incident?
Incident Timeline
Build a timeline of key incident events below
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Event Date / Time
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Event Description
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What were the weather / environmental conditions at the time of the incident?
- Clear
- Cloudy
- Rain
- Snow
- Windy
- Heatwave
- Haze
- Other
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Describe the weather / environmental conditions at the time of the incident
Evidence and Attachments
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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
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Evidence Description
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Evidence ID number (if applicable)
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Type of evidence
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Photos of evidence (if applicable)
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Please detail any further information regarding this evidence (if applicable)
Vehicle Log
Please log all relevant vehicle details below
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Vehicle Make
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Vehicle Model
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Vehicle Registration
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Driver (if applicable)
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Photos of equipment (if applicable)
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Please detail any further information regarding this vehicle (if applicable)
Damage Log
Please log all relevant damage details below
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Damage description
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ID number (if applicable)
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Photos of damage (if applicable)
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Please detail any further information regarding this damage (if applicable)
Other Items Log
Please log all relevant details of other items below
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Item description
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ID number (if applicable)
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Photos of item (if applicable)
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Please detail any further information regarding this item (if applicable)
Equipment Log
Please log all relevant equipment details below
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Equipment Make
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Equipment Model
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Equipment ID number (if applicable)
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Photos of equipment (if applicable)
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Please detail any further information regarding this equipment (if applicable)
People involved
Please document all people involved in this incident
Person
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Full Name
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ID number
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Contact phone number
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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
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Describe this person's relation to the incident
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Please describe this person's involvement with the incident, including all relevant information
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Attach any relevant photos regarding this person
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Do you want to log a statement for this person?
Statement
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Statement regarding incident
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Person Signature
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Date & Time of Statement
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Has this person sustained an injury?
Injury Details
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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
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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
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Describe this injury or illness
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What was the cause of this injury or illness?
Corrective Actions
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Are corrective/further actions required with regard to this incident?
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Please add any corrective actions to the appropriate questions above before completing this incident investigation
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Have all required corrective actions been added as Actions to this inspection?
Root Cause Analysis / Contributing Factors
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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
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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.
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Has the root cause of this issue been able to be identified?
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Why is the root cause for this issue unable to be identified at this time?
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How likely is this incident to reoccur in future?
- Certain
- Very Likely
- Likely
- Unlikely
- Very Unlikely
- Never
- Unclear / Not Determinable
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What is the root cause of this incident? Please consider and include all contributing factors
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Has the root cause of this issue been rectified or eliminated?
Sign Off
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Further action/follow-up/investigation required?
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Name of person/people to follow up
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Name & Signature of Investigator
