UOB INVESTIGATION OF AN INCIDENT

• Document No.

• Document header title

• Document prepared by

• Document file name (this will be used for the file name if the document is exported to word or pdf)

• Conducted on

  Date

Reporter

• Reporter name

• Reporter relationship with University

  Employee

  Student

  Visitor

  Contractor

  Other
• Reporter contact address
  Address

• Reporter contact phone number

• Reporter contact email

• Report date

  Date

Report type

• Type of report made

  Written statement

  Verbal statement

  Findings statement

  Site visit

• Incident I'd number

• Incident summary

Incident

• Incident date

  Date

Report

• Enter report elements

REPORT(S)

• Report element

  Statement

  Findings

  Source

• Record incident cause(s)

  Off

  On

Causes

• Enter incident causes

CAUSE(S)

• Incident cause

  Immediate cause

  Underlying cause

  Root cause

Signatures

• Reporter

  Sign

• Add other signatures

Other persons

• Add signature

  Sign