Incident Investigation Report

Incident Investigation Report

FILL OUT THE FORM BELOW AND SUBMIT
Project Number:
Person Completing Report:
Project Name:
Report Completed By:
Directly Involved (Non-Injured)InjuredSupervisorOther
Superintendent:
General Incident Details:
1. How did the incident occur?
2. What were the injuries or damage resulting from the incident?
3. Date & Time of Acident:
4. When was the incident reported?
Involved Parties:
5. Injured Person(s):
6. Involved/Injured Person Statement:
Signature of Involved Persons (1)

Powered by Jotform SignLimpiar
8. Witness (1):
Witness (1) Statement:
Medical
9. Did the injured party receive medical attention?
10. Was the injury treated on site, urgent care or hospital?
Medical Updated
11. What were the Indings of the injury?
12. Did the worker receive a clear to work letter?
13. Was there lost time? $so, how many days?
Root Cause Analysis:
14. Why did the incident happen? What were the underlying causes?
15. What could have been done to prevent the incident?
Preventive Measures:
16. What corrective actions will be implemented to prevent a recurrence?
17. What training or information was provided to the parties involved regarding safety procedures?
Conditions and Environment:

Type a question