Incident Investigation Report

INCIDENT INVESTIGATION REPORT

Instructions: Complete this form as soon as possible after an incident that results in serious injury or illness. (Optional: Use to investigate a minor injury or near miss that could have resulted in a serious injury or illness.)
Property*
This is a report of a:*
This report is made by:*

EmployeeSupervisorTeamOther
Date of Incident:*

DayMonthYear
STEP 1: INJURED EMPLOYEE

Complete this part for each injured employee
Name:*

First NameLast Name
Department:*
Job title at time of incident:*
Date of Birth:*

DayMonthYear
Gender:*

MaleFemaleOther
This employee works:*

Regular full timeRegular part-timeSeasonalTemporary
Months with this employer:*
Months doing this job:*
Nature of injury: (most serious one)*

Abrasion, scrapesAmputationBroken boneBruiseBurn (heat)Burn (chemical)Concussion (to the head)Crushing InjuryCut, laceration, punctureHerniaIllnessSprain, strainDamage to a body system:Other
Part of body affected: (place a cross in all areas that apply)*
STEP 2: DESCRIBE THE INCIDENT
Exact location of the incident:*
Exact Time of the incident:*

Hours Minutes

AM/PM Option
What part of employee’s workday?*

Entering or leaving workDoing normal work activitiesDuring meal periodDuring breakWorking overtimeOther
Names of witnesses (if any):
What personal protective equipment was being used (if any)?*
Describe, step-by-step the events that led up to the injury. Include names of any machines, parts, objects, tools, materials and other important details:*
Upload Supporting Documents:

Witness Statements / Photographs / Maps / Drawings
Cancelof
STEP 3: WHY DID THE INCIDENT HAPPEN?
Unsafe workplace conditions: (Check all that apply)*

Inadequate guardUnguarded hazardSafety device is defectiveTool or equipment defectiveWorkstation layout is hazardousUnsafe lightingUnsafe ventilationLack of needed personal protective equipmentLack of appropriate equipment / toolsUnsafe clothingNo training or insufficient trainingOther
Why did the unsafe conditions exist?*
Unsafe acts by people: (Check all that apply)*

Operating without permissionOperating at unsafe speedServicing equipment that has power to itMaking a safety device inoperativeUsing defective equipmentUsing equipment in an unapproved wayUnsafe liftingTaking an unsafe position or postureDistraction, teasing, horseplayFailure to wear personal protective equipmentFailure to use the available equipment / toolsOther
Why did the unsafe acts occur?*
Is there a reward (such as “the job can be done more quickly”, or “the product is less likely to be damaged”) that may have encouraged the unsafe conditions or acts?*

YesNo
If yes, describe:
Were the unsafe acts or conditions reported prior to the incident?*

YesNo
Have there been similar incidents or near misses prior to this one?*

YesNo
STEP 4: HOW CAN FUTURE INCIDENTS BE PREVENTED?
What changes do you suggest to prevent this incident/near miss from happening again?*

Stop this activityGuard the hazardTrain the employee(s)Train the supervisor(s)Redesign task stepsRedesign work stationWrite a new policy/ruleEnforce existing policyRoutinely inspect for the hazardPersonal Protective EquipmentOther
What should be (or has been) done to carry out the suggestion(s) checked above?*
STEP 5: WHO COMPLETED AND REVIEWED THIS FORM? (PLEASE PRINT)
Name of person completing report:*
Position/Job Title:*
Names of investigation team members:
Signature of person completing report:*

Clear
General Managers Email:*
A copy of this report will be sent to this managers email upon clicking Submit.
Please verify that you are human:*
Should be Empty:

INCIDENT INVESTIGATION REPORT

STEP 1: INJURED EMPLOYEE

STEP 2: DESCRIBE THE INCIDENT

STEP 3: WHY DID THE INCIDENT HAPPEN?

STEP 4: HOW CAN FUTURE INCIDENTS BE PREVENTED?

STEP 5: WHO COMPLETED AND REVIEWED THIS FORM? (PLEASE PRINT)