Vital Training Services- Incident Investigation

• Document No.

• Audit Title

• Client

• Conducted on

  Date

• Prepared by

• Location
  Address

• Every effort should be made to accurately and completely fill out this document. Additional information pertinent to the investigation may be available at a later date; therefore, this document cannot be considered as all inclusive.

• Employer

• Incident Site

• Location of Incident

• Date and Time of Incident

  Date

• Employee Name

• Job Classification

• Employee's Supervisor

Investigation Team Members

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  Sign

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Incident Information

• Incident Description ( What happened and Where)

• Witness(es)

• Immediate Corrective Actions

Contributing Factors

• Material, Equipment, Personal Protective Equipment and Enviroment:

  Yes

  No

  N/A

• If yes, please explain

• Training

  Yes

  No

  N/A

• If yes, please explain

• Safety Systems

  Yes

  No

  N/A

• If yes, please explain

• Human Factors/Ergonomics

  Yes

  No

  N/A

• If yes, please explain

• Task Instructions

  Yes

  No

  N/A

• If yes, please explain

• Rules and Procedures

  Yes

  No

  N/A

• If yes, please explain

• Other Factors

  Yes

  No

  N/A

• If yes, please explain

Root Cause

• Root Causes

Incident Pictures

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  Media

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  Media

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  Media

• Description

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  Media

• Description

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  Media

• Description

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  Media

• Description

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  Media

• Description

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  Media

• Description

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  Media

• Description

Status of Incident

• No Injury/Reporting Purposes Only

• First Aid Case

• Recordable Case

• Medical

• Return To Work Case

• Lost Time Accident

• Fatality

• Medical

• Return To Work Case

• Lost Time Accident

Cause of Accident

• Hazardous Condition

• Defective Tools/Equipment

• Procedures Not Followed

• PPE Not Used

• Other

• If other, please explain