Incident Investigation Report Form

INCIDENT INVESTIGATION REPORT

Please Note The investigation report is to be completed after every incident

IMPORTANT! REVIEW INCIDENT REPORT, INTERVIEW CASUALITY, WITNESS, OTHER EMPLOYEES & MANAGEMENT

SAFETY COORDINATOR NAME

CURRENT DATE

INSTRUCTIONS - EXPLANATION OF CAUSE - HOW DID THE INCIDENT OCCUR? DETERMINE PERSONEL & JOB FACTORS

DATE OF INCIDENT

NAME OF INVOLVED PARTY

RISK ASSESSMENT (FREQUENCY). How often the task that led to the incident is completed

Very Frequent Frequent Occasional Rare

RISK ASSESSMENT (SEVERITY). The actual or potential severity

Extreme Major Moderate Minor

WHAT ACTIONS OR CONDITIONS CAUSED OR COULD HAVE CAUSED THE EVENT? Consider equipment, environment, personnel, management & and other

CORRECTIVE ACTION PLAN 1

PERSON RESPONSIBLE

COMPLETION DATE

CORRECTIVE ACTION PLAN 2

PERSON RESPONSIBLE

COMPLETION DATE

FILE UPLOAD