Incident Investigation Report

Incident Report
- Incident Classification
- Hazard IDNear MissIncidentAccident
- First AidMedical AidModified WorkLost Time
- YesNo
- Incident / Injury Information
- Incident Date
  
  MonthDayYear
- Time of Incident
  
  :HourMinutesAM/PM Option
- Injured Workers Name
  
  First NameLast Name
- Occupation
- Location Of Incident
- YesNo
- YesNo
- Supervisor's Name
  
  First NameLast Name
- Detailed Description Of The Incident
- Body Part (s) Injured
- EyesHeadFaceNeckHandFingersWristElbowArmShoulderBackKneeLegBody/ ChestGroin/ HipAnkleFoot (includes toes)Other
- Nature Of Injury
- CutFractureAllergySprain/ StrainScrapeShockContusionBruiseBurnPunctureAmputationInfectionHerniaLoss of ConsciousnessNon-Work Related Injury/IllnessWelding Flash
- Incident Caused By
- Struck ByTripOverexertionContact with Hot/Cold SurfaceFall from Same LevelErgonomically InducedForeign BodyEnvironmental ExposureFall from ElevationCaught by / BetweenMotor Vehicle IncidentChemical ExposureSlipRepeated ExposureViolence / AggressionOther
- Direct Causes
- Equipment Operation Without AuthorityFailure to Secure / Improper LoadingProper PPE not Worn / Used IncorrectlyImproper Position for TaskImproper LiftingAssistance UnavailableImproper Energy IsolationImproper Blocking / CribbingFailure to Identify / Address HazardHazard Assessment not CompletedProcedure or Practice not FollowedServicing Equipment in OperationInadequate Instructions / ProceduresInadequate Preparation / Planning
- Making Safety Devices InoperableProper Tools / Equipment UnavailableDefective Tools / EquipmentInadequate MaintenanceInadequate InspectionIncompatible Equipment / ToolsInadequate GuardingImproper use of Mobile EquipmentInadequate Warning System / SignageInadequate DesignInadequate Pre-InspectionTool used Incorrectly
- Fire and Explosion HazardPoor HousekeepingWork Area CongestionRestricted Work SpaceNoise ExposureTemperature ExtremesInadequate LightingInadequate VentilationHarmful Substance PresentGround / Surface ConditionsYard ConditionsWeather ConditionsLimited Visibility
- Root Causes
- Unclear or Conflicting Reporting RelationshipInadequate OrientationInadequate TrainingInadequate Standard PracticeInadequate Safe Work ProcedureInadequate Assessment of RiskInadequate Evaluation of ChangeImproper Transporting of MaterialsInadequate Development of ProcedureInsufficient Maintenance ScheduleInadequate Assessment of Ergonomic FactorsInadequate Work Planning
- Substandard Housekeeping PracticesJHA Process not ImplementedLack of SupervisionInadequate SupervisionInadequate Communication of StandardSWP / Practice not ImplementedInadequate Design CriteriaInadequate MonitoringInadequate Purchasing StandardsInadequate Selection of ContractorInadequate Maintenance ProgramInadequate Monitoring of ComplianceInadequate Control MeasuresLack of Inspection Process
- Lack of ExperienceMisunderstood DirectionFailure to Recognize HazardWorker FatigueLimited Physical CapabilitiesUnder the Influence of Alcohol / DrugsLack of Knowledge Relating to HazardEyes not on TaskRushingOperating at unsafe speed
- FireTornadoExtreme Weather
- Summary of Direct and Root Causes
- List all Direct and Root causes that you identified with check marks above - Add as many as you need by clicking the + button to add a new line*
- Corrective Actions
- Determine a corrective action based on each direct and root cause listed above - Add as many as you need by clicking the + button to add a new line*
- Lead Investigator
  
  First NameLast Name
- Investigator #2
  
  First NameLast Name
- Investigator #3
  
  First NameLast Name
- Date Report Completed
  
  MonthDayYear
- Reviewed By
  
  First NameLast Name
- Position
- Date Report was Reviewed
  
  MonthDayYear
- Should be Empty:

Incident Report

Incident Classification

Incident / Injury Information

Body Part (s) Injured

Nature Of Injury

Incident Caused By

Direct Causes

Root Causes

Summary of Direct and Root Causes

Corrective Actions