Accident/Injury/Incident Follow-Up Form
Incident Classification
Employee Filling Out This Form
First Name
Last Name
Type a question
First Aid
Recordable
Lost Time
SIF Exposure
Fatality
Property Damage
Theft
Vehicle Incident
Summary of Incident
Please summarize in 5-6 sentences
Timeline of Events
From JHA to completed response
Name(s) of Witness(es)
Summary of Witness Statements
Energy Involved
Description
Root Cause Analysis
Immediate Cause
Contributing Factors
System Failures
Corrective Actions Needed
What corrective actions need to be taken to prevent this type of incident from happening in the future? Who should be in charge of making sure those actions happen, and when should it be due?
Action 1
Owner of Correction Action 1
First Name
Last Name
Action 1 Due Date
-
Month
-
Day
Year
Date
Action 2
Owner of Correction Action 2
First Name
Last Name
Action 2 Due Date
-
Month
-
Day
Year
Date
Action 3
Owner of Correction Action 3
First Name
Last Name
Action 3 Due Date
-
Month
-
Day
Year
Date
Please list any other corrective actions you think need to be taken if there was not enough room above. Please include who should own the action and when it should be due.
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