Title Page
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Site conducted
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Conducted on
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Prepared by
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Location
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Type
Incident Details and Root Cause Analysis
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Describe the incident or near-miss
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What was the immediate cause of the incident or near-miss?
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What were the underlying causes or contributing factors?
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Was there any damage or injury?
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Please describe
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Corrective Actions Taken
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What corrective actions were taken immediately following the incident or near-miss?
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Were the corrective actions effective in addressing the root cause?
Communication of Findings to Workers
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Have the findings and corrective actions been communicated to all relevant workers?
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How were the findings communicated? (e.g., meeting, notice board, etc.)
Follow-Up on Corrective Actions
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Is there a follow-up plan in place to ensure corrective actions are maintained?
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What is the status of the follow-up plan?
Summary of Findings
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Summary of Findings
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Actions Required
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Person Responsible for Actions
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Due Date for Actions
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Sign-Off
