Investigator Name
*
Investigators Email
example@example.com
Is this:
Foreman's / Supervisor Preliminary Incident Information
A continuing investigation
A final investigation report
Incident Investigation Report
Incident Investigation Report
Job Number
Project Name
*
List office or Shop if not project related
Investigator Name
*
Investigators Email
*
example@example.com
Reported By
*
You
Your Email
*
example@example.com
Incident Title
*
Incident Type
*
Please Select
Serious Illness/Injury
First Aid
Property Damage
Violence/Harassment
Environmental
Fire
Near Miss
Other
Date Report Completed
*
-
Month
-
Day
Year
Date
Hour Minutes
Date of Incident
*
-
Month
-
Day
Year
Date
Hour Minutes
Date Incident Reported
*
-
Month
-
Day
Year
Date
Hour Minutes
Weather Conditions
*
Name first and last
Direct Supervisor
*
Name first and last
Incident Location
*
Was post Incident D&A Testing Conducted
*
Please Select
Yes
No
Provide detailed explanation for bypassing post accident testing
Activity Being Preformed at the Time of Incident
*
Please Select
Regular Work Activities
Driving (on-site)
Driving (off-site)
Uncommon Work Activities
Non Standard Work Activities
Other
Description of the Incident
*
Direct Causes
*
1. Failure to communicate/coordinate
12. Failure to secure
2. Failure to use PPE properly
13. Failure to identify hazard/risk
3. Failure to follow procedure/practice/policy
14. Improper placement
4. Improper technique (lifting/pushing/pulling)
15. Using defective equipment/tools
5. Improper loading
16. Horseplay
6. Under the influence of drugs/alcohol
17. Using equipment improperly
7. Operating or working at improper speed
18. Inadequate guards or barriers
8. Inadequate or improper protective equipment
19. Congested or restricted area
9. Poor housekeeping
20. Inadequate information
10. Inadequate preparation/planning
21. Inadequate support/assistance
11. Road conditions
22. Weather conditions
Other
Indirect Causes/Contributing Factors
*
23. Lack of knowledge
29. Lack of skill
24. Lack of training
30. Physical/phycological stress
25. Inadequate leadership/supervision
31. Inadequate maintenance
26. Inadequate tools/equipment/materials
32. Critical task analysis
27. Emergency preparedness
33. Procedure evaluation
28. Hiring and placement
Other
Include Any Direct/Indirect Causes Not Listed
Describe/Explain all Identified Direct and Indirect Causes
*
Corrective Actions for all Identified Causes to Prevent Reoccurrence
Corrective Action
Assigned To
Projected Completion Date
Actual Completion Date
1
2
3
4
5
6
Corrective Actions for All Identified Direct & Indirect Causes
*
Additional Information
Include Any Relevant Photo's
Include Any Relevant Photo's
Include Any Relevant Photo's
Include Any Relevant Photo's
Signature of Investigator
Submit
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