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:

Other
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:

Other
This employee works:
Months with this employer:
Months doing this job:
Nature of injury: (most serious one)

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?

Other
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)

Other
Why did the unsafe conditions exist?
Unsafe acts by people: (Check all that apply)

Other
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?
If yes, describe:
Were the unsafe acts or conditions reported prior to the incident?
Have there been similar incidents or near misses prior to this one?
STEP 4: HOW CAN FUTURE INCIDENTS BE PREVENTED?
What changes do you suggest to prevent this incident/near miss from happening again?

Other
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:
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)