Information

  • Audit Title

  • Document No.

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Personnel

Only fill Out Section Pertaining To The Incident

  • Incident Type

Investigation Report

  • Company (Select Option)

  • Date and Time of Accident

  • Exact Location of Accident

  • Employee Name

  • Incident Number

  • Job Title

  • Date Hired (mm/dd/year)

General Information

  • Is this the employees first incident

  • If not, how many?

  • Where was the incident located

  • Job Name and Number

  • How many hours had employee worked this shift

Description of the Accident/Damage

  • Please describe what happened, in detail.

  • Photo of accident area. Please provide as many as needed.

Accidents /Incidents Conditions Involved

  • Employee Job Description

  • Hazardous Condition

  • Please describe if "Other"

  • Severity of Treatment

  • Was injured employee Hospitalized?

Property Damage - Complete and scroll down to Root Cause Analysis if over $1000 damage

  • What was the contributing factors

  • Write Description Of Incident

  • Property Damaged Type

  • Estimated Cost of Damage

  • Photo Damage

  • Mark location of damage or sketch

  • Locate Area

Body Part Injured

  • Eye(s)

  • Arm(s)

  • Elbow

  • Wrist

  • Hand

  • Buttocks

  • Leg(s)

  • Foot

  • Knee

  • Ankle

  • Back

  • Lungs / Throat / Mouth

  • Chest / Ribs

  • Abdomen

  • Groin / Genitals

  • Head / Neck

  • Face

  • Finger(s)

  • Toe(s)

Unsafe Act & Other Contributing Factors

  • Operating without Authority

  • Unsafe Carrying / Lifting

  • Taking Unsafe Position

  • Failure to use PPE or improper use of PPE

  • Failure to Secure Equipment

  • Equipment Failure

  • Poor or Inadequate Housekeeping

  • Operating at Unsafe Speed or Beyond Capacity

  • Congested Area

  • Accident Caused by Another Employee

  • Other (Specify)

Nature of Injury

  • Foreign Object

  • Cut

  • Bruise / Contrusion

  • Sprain / Strain

  • Fracture

  • Burn (Chemical)

  • Burn (Thermal)

  • Chemical Irritation

  • Amputation

  • Puncture Wound

  • Hernia

  • Dermatitis

  • Smashed / Pinched

  • Abrasion

  • Infection

  • Secondary infection

Accident Type

  • Struck By / Against

  • Caught In / Out / Between

  • Fall (Same Level)

  • Fall (Different Level) Height:

  • Slip / Trip

  • Vehicle Accident

  • Contact with Temperature Extremes

  • Repetitious Trauma

  • Over Exertion

  • Chemical Exposure

  • Skin

  • Inhalation

Protective Equipment

  • Required but NOT in Use

  • Required and IN Use

  • Not Required (May have reduced injury)

  • Not Required (would NOT have effected injury)

  • Specify Protective Equipment in Use

Actions to Prevent Accident / Incident Re-OCCURANCE

  • Restriction of Person(s) Involved

  • Reprimand of Person(s)Involved

  • Discipline of Person(s) Involved

  • Action to Improve Inspection or Monitoring

  • Action to Improve Construction

  • Investigate Better Method

  • Action to Improve Clean Up

  • Request Job Safety Analysis to be Done

  • Equipment Replacement or Repair

  • Action to Improve Design

  • Installation of Guard or Safety Device

  • Request Pre-Job Instructions

  • Correction of Unnecessary Congestion

  • Improve PPE

  • Inform Other Supervision

  • Request Safety Observation

Root Cause(s)- Anaylis

  • List any and ALL Root Causes

Indirect Cause(s)

  • List any and ALL Indirect Causes

Recommended Corrective Action(s)

  • ALL above listed items MUST be explained HOW reoccurrence will be prevented

Sign Off

  • Individual assigned responsibility for carrying out measures for preventing reoccurrence.

  • Date Corrective Action(s) to be completed

  • Project Manager

  • Safety Representative

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.