Incident Report - Full Investigation & Report

• Document Number from the first response form.

• Investigation conducted on

  Date

• Prepared by

Name of person(s) conducting this investigation

• Name

Incident Details

• Date of the incident?

  Date

• Date and time of the incident?

  Date

• Incident reported to?

• Site?

  Select

• Location

  Select

• Full incident description

• Incident description written by?

• Incident Outcome?

  Select

• Injury Catogery

  Select

• Injury to body part

  Select

• Circle injury area on the diagram

  Drawing

• Injury Catogery

  Select

• Injury to body part

  Select

• Circle injury area on the diagram

  Drawing

• Injury Catogery

  Select

• Injury to body part

  Select

• Circle injury area on the diagram

  Drawing

• Property damage resulted from?

  Select

• Product Damage resulted from

  Select

• Near Miss rating?

  Select
Name of person(s) involved in the incident

• Name

• Employment status

  Select

• Length(s) of service

  Select

Root Cause Analysis (5 Why)

• 1. Why did the incident happen?

• 2. Why did 1 happen?

• 3. Why did 2 happen

• 4. Why did 3 happen?

• 5. Why did 4 happen?

Evidence

• Add Photos / PDF Document

  Media
Action Outcome

• Category

  Select

• Recommendations

• Who Responsible

• By When

  Date

• Sign off

  Sign

• Please follow the steps below for sharing is the report after completion with other Managers and Leaders. NOTE: this report must be shared with the Safety Leadership group.

• Step 1

  

• Step 2

  

• Step 3

  

• Step 4

  

• Step 5