Title Page

  • Investigation conducted on

  • Prepared by

Incident Report

Incident Details

  • Date & Time of Incident

  • Incident Type (select all that apply)

  • Was first aid administered?

  • What kind of medical attention was administered?

  • Was the incident reported at the time of injury?

Injuried Person Information

  • Name of employee involved?

  • Employee Number

  • Employee Cell Phone Number

  • Employee Job Title

  • Employee Date of Birth

  • Employee Hire Date

  • How long has employee worked in current position?

  • Where did the injury occur?

Incident Summary

  • Describe what happened. Please be detailed but state only facts.

  • Take photos of the injury, equipment or property involved. Take photos from the North, South, East, and West. Close up and further back.

  • Does employee want to seek medical treatment beyond first aid?

Corrective Actions

  • Are corrective/further actions required with regard to this incident?

  • Please add any corrective actions to the appropriate questions above before completing this incident investigation

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Root Cause Analysis / Contributing Factors

  • What were the contributing factors to this incident occurring? (select all that apply)

  • A Root Cause Analysis (RCA) is the process of determining the cause of an incident. It requires consideration of all the factors that may have contributed to this incident occurring and deeply understanding the underlying cause. One tactic to determine this is through asking "Why?" five times, to uncover the core of a problem.

  • Has the root cause of this issue been able to be identified?

  • Why is the root cause for this issue unable to be identified at this time?

  • How likely is this incident to reoccur in future?

  • What is the root cause of this incident? Please consider and include all contributing factors

  • Has the root cause of this issue been rectified or eliminated?

  • How was the root cause rectified or eliminated?

  • Please attach any relevant photos or media

  • Please provide any relevant further details

  • How likely is this incident to reoccur in future?

Sign Off

  • Further action/follow-up/investigation required?

  • Name & Signature of Investigator

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.