Manager Investigation Report

• Employee Name

• Conducted on

  Date

• Prepared by

Employee Information

• Department

• Title

• # months in current position

• Date of Birth

  Date

• Date of Hire

  Date

Incident Information

• Date & Time of incident

  Date

• Amount of time on duty prior to incident

• Equipment involved

  Select Forklift Triple Pallet Jack Double Jack Single Jack Other

  • Forklift
  • Triple Pallet Jack
  • Double Jack
  • Single Jack
  • Other

• Other

• Equipment #

• Date and time Supervisor was notified.

  Date

• Specific work method being performed at the time of the incident.

• How many employee perform this same task?

• Description of the incident and any injuries, illness or property damage.

• Have there been similar incidents or near misses prior to this? If yes, explain. If no, mark NA.

• Did an unsafe act contribute to this incident?

  Yes

  No

• If yes, select all that apply from the list below. If no, mark NA.

• Unsafe Acts

  Select Lack of training Lack of skill Distracted Failure to anticipate Operating without authority Disabled safety device Working on moving equipment Poor sanitation Operating at unsafe speed Unsafe lifting Failure to use available PPE Other NA

  • Lack of training
  • Lack of skill
  • Distracted
  • Failure to anticipate
  • Operating without authority
  • Disabled safety device
  • Working on moving equipment
  • Poor sanitation
  • Operating at unsafe speed
  • Unsafe lifting
  • Failure to use available PPE
  • Other
  • NA

• Other

Review of Training Records

• Was training required for this task?

  Yes

  No

• Was training required for this task?

  Yes

  No

• Was training documented?

  Yes

  No

• Describe any 'no' answers or mark NA

Unsafe Conditions

• Did unsafe conditions contribute to this incident?

  Yes

  No

• If yes, mark all that apply below. If no, mark NA.

• Unsafe Conditions

  Select Inadequate Guarding Unsafe equipment Improper lighting Unsafe position Weather conditions (rain, snow, etc.) Uneven surface Other NA

  • Inadequate Guarding
  • Unsafe equipment
  • Improper lighting
  • Unsafe position
  • Weather conditions (rain, snow, etc.)
  • Uneven surface
  • Other
  • NA

• Other

5 Whys

• Why did the incident occur?

• Why #2

• Why #3

• Why #4

• Why #5

• Additional Questions (if needed)

Root Cause Analysis

• What is the root cause of the incident?

• List any contributing factors or mark NA

• List any interim protections or mark NA

• What are the corrective actions?

• Who is responsible for the corrective actions?

• Date Completed

  Date

Media

• Add media

  Media

• Add drawing

  Drawing

Executive Review

• Supervisor Signature

  Sign

• Department Manager Signature

  Sign

• Safety Manager Signature

  Sign

• VPO/President Signature

  Sign