Incident Investigation / Root Cause
Safety follow up on submitted incidents
Incident closed
Yes
No
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
Lead Safety
First Name
Last Name
Email of Lead Safety
example@example.com
Select which company the report is for
Atwell
RVi
Other
Location of incident
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Incident Type
Please Select
Injury
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 Cost
Please Select
Minor 0$ -$3000
Medium $3001 - $5000
High $5001 - $10,000
Extreme $10,001 and Greater
Company Reputation
Please Select
Low risk to Company
Medium Risk to Company
High Risk to Company
Extreme Risk to company
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
Discription of incident
Original incident report description
Copy and past the original description here
Correction to original description
Describe site conditions
List the conditions in the immediate area of incident
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
Other
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
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