• 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.)

  • This is a report of a:
  • Date of Incident
     - -
    2 digit month, 2 digit day, 4 digit year
  • This report is made by:

  • Step 1: Injured employee

    (complete this part for each injured employee)
  • Gender:
  • Part of body affected: (shade all that apply)
  • Nature of injury: (mostserious one)

  • This employee works:

  • Step 2: Describe the incident

  • Exact Date and Time:
     - -
    2 digit month, 2 digit day, 4 digit year :
  • What part of employee’s workday?

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  • Step 3: Why did the incident happen?

  • Unsafe workplace conditions: (Check all that apply)

  • Unsafe acts by people: (Check all that apply)

  • Is there a reward (such as “the job can be done more quickly”, or “the product is less likely to be damaged”) that mayhave encouraged the unsafe conditions or acts?
  • 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?

  • Step 5: Who completed and reviewed this form?

  • Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Date
     - -
    2 digit month, 2 digit day, 4 digit year
  •  p. 443.979.7171 AAA Physical Therapy, LLC
    admin@AAAPhysicalTherapy.com
    8975 Guilford Rd Ste 170 Columbia, MD 21046    		  f. 667.200.5908
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