Incident Investigation Report

Incident Investigation Report

Incident Report
- Incident Classification
- Select a category
- Incident resulted from work-related activities
- Incident / Injury Information
- Incident Date
  
  MonthDayYear
- Time of Incident
  
  :HourMinutesAM/PM Option
- Injured Workers Name
  
  First NameLast Name
- Occupation
- Location Of Incident
- Drug and Alcohol Testing Required:
- Witness Statements (Attach to report)
- Supervisor's Name
  
  First NameLast Name
- Detailed Description Of The Incident
- Body Part (s) Injured
- Check All that apply
  
  Other
- Nature Of Injury
- Check All that apply
- Incident Caused By
- Check all that apply
  
  Other
- Direct Causes
- Safe Work Practice / Procedure
- Tools and Equipment
- Environment
- Root Causes
- Job Factors
- System Factors
- Personal Factors
- Natural Factors
- 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: