Information
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Document No.
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Incident Investigation Report (List Job Number and Name Below)
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Conducted on
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Location
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Report Conducted By
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Employee Involved
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Witnesses Involved
Supervisor Report
Supervisor's Report
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Supervisor's Name
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Date and Time of Incident
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Address Incident Occurred
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Describe what the employee was doing when the incident occurred and what tools were being used
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Did the incident cause injury or illness to anyone
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Add person with Injury or Illness
Injury or Illness
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What side on the body did the injury or illness occur
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What part of the body did the injury occurr
- Head
- Neck
- Shoulder
- Chest
- Upper Back
- Lower Back
- Elbow
- Forearm
- Wrist
- Hand
- Leg
- Knee
- Foot
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Type of Injury
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What property/equipment was damaged (If yes, take photos and give a description)
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Add damaged property or equipment
Damaged property/equipment
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What type of property or equipment was damaged?
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Who is the owner of property or equipment?
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Was the employee properly using and wearing all required Personal Protective Equipment (PPE)?
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Was the employee using proper procedures for the task?
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Did the employee promptly report the injury or illness?
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Additional Comments
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The above section is completed to the best of knowledge, and includes all the details of the accident I know (print name then sign)
Employee's Report
Employee's Report of Incident
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How many employees received injury or illness from the incident?
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Injured or Ill employee's information
Employe Information
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Employee's Name
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Date of Birth
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Social Security No.
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Phone Number
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Address
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Sex
Incident Information
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Date and Time of injury/illness
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Date Reported
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Name of the person the injury/illness was reported to?
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Location on the job-site where the accident happened?
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What task was being performed when the injury/illness occurred?
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Please describe, In detail, what took place before, during and after (arrival to medical facility) the Incident?
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Did the incident cause you injury or illness?
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Description of your injury / illness
Add injury or illness
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What side of the body did the injury or illness occur?
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What part of the body was injured?
- Head
- Neck
- Shoulder
- Chest
- Upper Back
- Lower Back
- Elbow
- Forearm
- Wrist
- Hand
- Leg
- Knee
- Foot
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Type of injury?
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Did you seek medical care? (if yes, name of medical facility)
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Did the incident cause damage to property or equipment?
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List the property or equipment damaged and what kind of damage it sustained.
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List others employees who witnessed the accident (include names and phone numbers)
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Additional Comments
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The above section is completed to the best of knowledge, and includes all the details of the accident I know (print name then sign)
Witness Statements
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Witness Statement
Add Witness Statement
Witness Information
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Witness' Name
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Address
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Phone Number
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Supervisor Name And Phone Number
Incident Information
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Date and Time Incident occured
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Location on the job-site the incident occurred
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Please describe, in detail, what took place before, during, and after the incident. What was your location from the incident.
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The above section is completed to the best of knowledge, and includes all the details of the accident I know (print name then sign)
Safety Department
Safety Department
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Has the incident site been made safe?
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Does anyone have injury or illness caused by the incident?
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If the injury requires more than first-aid, a mandatory drug-screen needs to be performed on the injured employee.
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Photos of the injury/illness
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Comments from the injured or ill employee
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Does any property or equipment have damage due to the incident?
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List out damaged property and/or equipment
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Photos of damaged property and/or equipment
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Additional Comments
Job-site survey
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Location
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Date and time recorded
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Photos of the Incident site
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Notes
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Diagram
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The above section is completed to the best of knowledge, and all the information, notes, photos in this section are factual and have not been alter to my knowledge. (print name then sign)
