Information
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Site conducted
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Branch Location
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Affected Employee's Name
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Date of Hire
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Employee Position
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Date of injury
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Date of Report
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Person completing the investigation:
Investigation
SITUATION
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Description of Injury (SBI Model)
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Body Part Injured
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Time of Injury
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Time Employee Started
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Location where incident happened
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Was there any witness(es)? If yes, provide name(s).
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Name of Witness
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Was a drug screen performed?
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Why not?
Root Cause Analysis
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Contributing (underlying) Factors or Behaviors:
Training for Affected Employee
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Training for affected employee?
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What is the target completion date?
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Who will complete the training and how?
Training for the Workgroup
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What training will the workgroup get?
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What is the target completion date?
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Who will complete the training and how?