Incident Investigation Checklist
Safety Checklist for incidents
List the incident being investigated
Name and date
Todays Date
/
Month
/
Day
Year
Date
Date reported
/
Month
/
Day
Year
Date
Incident Date
/
Month
/
Day
Year
Date
Reported Late
*
Yes
No
Regional Safety Manager
First Name
Last Name
Email Regional Safety Manager
example@example.com
Select which company the report is for
*
Atwell
RVi
Centurion
Job number
*
0000100 Should be used if no job number is present
Location of incident
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Incident Type
*
Please Select
Injury
MVA
NP MVA
Property Damage
Theft
Near Miss
Injury Type
Please Select
First Aid
Medical Treatment only (Recordable)
Restricted duty
Lost Time
Fatality
Only select when confirmed with Safety Director
MVA Type
Please Select
Preventable (At fault)
Non Preventable
Severity
Please Select
Minor
Major
Severe
Catastrophic
Company Reputation
Please Select
Low risk to Company
Medium Risk to Company
High Risk to Company
Extreme Risk to company
Injury Treatment Information
Please Select
First Aid treated on site
Treated at Local Clinic
Treated at Emergency Room
Transported by EMS to Emergency room
Medical Facility Name
Phone Number of Clinic
Please enter a valid phone number.
Format: (000) 000-0000.
Regulatory reporting triggers
Employee was hospitalized more than 24 hours
Employee have a amputation, or eye loss
Resulted in fatality
Affected Body Part
Head
Eye
Face
Neck
Right Shoulder
Left Shoulder
Back
Torso
Right Arm
Left Arm
Right hand
Left Hand
Right Fingers
Left Fingers
Right leg
Left Leg
Right knee
Left Knee
Right foot
Left Foot
Right Toes
Left Toes
Which finger(s)
Thumb
Pointer finger
Middle Finger
Ring Finger
Pinky Finger
Which Toe(s)
Big Toe
Next to Big Toe
Middle Toe
Next to little toe
Little Toe
Check all that apply
Job Hazard Analysis JHA
Proper PPE was worn
Equipment was inspected
Did employee do a 360 walk around of the vehicle before incident
Was employee doing his regular job?
Other
MVA questions
Was employee at fault for MVA
Was employee not at fault for the MVA
Was the vehicle drivable?
Yes
No
Name of towing company
Phone Number of towing company
Please enter a valid phone number.
Format: (000) 000-0000.
Location of MVA
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Name of the responding law enforcement officer
Was citation issued to employee?
Yes
No
Discription of incident
Incident Details
List any witnesses
Describe site conditions
List the conditions in the immediate area of incident
Potential Contributing Factors
Hurrying
Inattention
Improper use of Tool
Communication
Equipment failure
Housekeeping
Job Knowledge
Deviation from Normal procedures
Fatigue/other physical factors
Equipment design
PPE
Cramped work area
Weather
Lighting
Preventative maintenance
Time pressure to get job completed
Other
Detail Contributing factors
If further details are needed to describe the contributing factors
List the Root Cause of incident
List Corrective Action
List the CA , Asigned to complete and date to complete
Upload files documents and photos
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Incident closed
Yes
No
Submit
Should be Empty: