Initial Incident Investigation Report

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Date & Time The Incident Occurred Or Was Discovered

• Date & Time The Incident Occurred /Discovered

  Date

• Date & Time Reported

  Date

• Location Of the Incident

• Add location
  Address

Incident Classification

• Information Report / Non-Work Related

• Near Miss

• Spill / Release

• Property Damage

• Illness

• Injury

• Injury Classification

  Minor First Aid

  First Aid

  Recordable

  Restricted Duty

  Lost Time

Employee Information

• Employee's Full Name

• Employee ID Number

• Employee Gender

  Male

  Female

• Employee's Date Of Birth

  Date

• Short Service Employee?

  Yes

  No

• Employee's Phone Number

• Describe the location and nature of the injury.

Property Damage

• Property Owner's Information

• Description of property and damage.

Utility Damage

• Utility Owner

• Type of Utility

  Select Electrical Line Telephone Line Television Cable Fiber Optic Line Pipeline (Gas/Oil) Water Line Sewer Line Other

  • Electrical Line
  • Telephone Line
  • Television Cable
  • Fiber Optic Line
  • Pipeline (Gas/Oil)
  • Water Line
  • Sewer Line
  • Other

• Cable / Line Size

• Were Locates Requested?

  Yes

  No

  N/A

• One-Call Ticket Number

• Was The Utility Located?

  Yes

  No

  N/A

• Were The Locates Correct?

  Yes

  No

  N/A

Description Of Events

• Brief Description Of Incident

• List Causes Or Factors

• Preventable Or Non-Preventable

  Preventable

  Non-Preventable

• List Prevention Measures Taken

• Attach Photos

  Media

• Photo Notes: