• Incident Investigation Title

  • Document No.

  • Client

  • Location
  • Personnel involved in the investigation

  • Conducted on

  • Prepared by

  • Date and time of incident:

Incident summary:

  • Name of injured person or person reporting the incident

  • What type of incident occurred

  • What was the injury type

  • What was the injury category?

  • What body part was affected

  • Provide a summary of the incident, giving as much detail as possible

  • Add photographs where possible

Task being conducted:

  • Enter details of task being conducted:

Other persons involved / witnesses

  • Name: Position: Location at time of incident:

Reference documentation:

  • Procedure used?

  • Work method statement used?

Immediate Actions:

  • List immediate actions taken as a result of the incident:

Supplementary Actions:

  • List actions taken to prevent recurrence:

Time line / Sequence of events:

  • Describe the sequence of events from initial report and interviews:

  • Draw the timeline if possible:

Contributing Factors: Task / Procedural

  • Was a safe work procedure available?

  • Was a safe work procedure used?

  • Was a risk assessment conducted?

  • Were controls in place as per the RA / WMS?

  • Were appropriate tools and materials available?

  • Were they used?

  • Were personnel were trained to conduct the work?

  • Work Activity Briefing (WAB) was conducted noting all hazards?

  • The task remained unchanged from original job?

Contributing Factors: Equipment / Substance

  • All equipment was in good working order?

  • Was the equipment used as designed?

  • Equipment is regularly serviced?

  • Were pre-start checks conducted and correct?

  • Personnel were appropriately trained to operate equipment?

  • MSDS (material safety data sheet) are available on site?

  • All labels and signs in place and easy to read?

  • Appropriate PPE is available?

  • PPE was worn correctly?

Contributing Factors: Environment / Behaviour

  • Weather conditions were not a factor of the incident?

  • Area was clean and tidy, poor housekeeper was not a factor?

  • Was it too hot or too cold?

  • Was it noisy?

  • Was lighting adequate?

  • Was fatigue evident?

  • Was alcohol or another impairment evident?

  • Was the task being rushed?

  • Were workers complacent?

  • Was poor vision a factor?

  • Were health issues a factor?

  • Workers were experienced and adequately supervised?

Other Contributing factors:

  • List any other contributing factors:

  • Add photos as required


  • Enter investigation conclusions:


  • Enter recommendations:

  • Signature of investigating officer:

  • Signature of manager:

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.