Incident Investigation Form Download PDF Order Number Instructions: Obtain statements from the injured employee and any witnesses to include what happened, what caused the incident and what were the contributing factors to the incident. To do this, reconstruct the sequence of events that led to the injury. Attach additional sheets if necessary. Provide copies of the completed form and all Incident Statement Forms to: agency safety coordinator, the field safety coordinator, supervisor and bureau director or field manager. Injured Employee Data Employee Name * Working Title * Personnel Number * Date of Incident * Time of Incident * Examples: 01:00am, 11:30pm Claim Number (if known) Work Organization/Location * Supervisor * Supervisor Telephone Number * Supervisor Email * Incident Description Where did the incident happen and who was involved? * Provide a full description of the surroundings of the location and the individuals involved. What was happening at the time of the incident and why was it taking place. * What events lead up to the incident? * Describe the sequence in order and when they took place. What exactly caused the injury and how did it happen? What mechanics, equipment, or tools were involved? * Describe the injury. * Include the affected body part(s) and injury type or indicate no injury occurred. If a physical injury was avoided, describe what happened that could have potentially resulted in injury. * Additional Information Provide any additional information important to the investigation (pictures taken and evidence collected). Upload Files Allowed file types: jpg, jpeg, png, txt, pdf, doc, docx Initial Investigator Incident Investigator Name * Date of Investigation * Time of Investigation * Examples: 01:00am, 11:30pm CHECK ALL DIRECT CAUSES THAT APPLY What CONDITION of tools, equipment, or work area contributed to the incident * Not Applicable Close Clearance/Congestions Hazardous Placement Inadequate Warning System Improper Material Storage Inadequate/Improper PPE Floors/Work Surfaces Inadequate Ventilation Inadequate Illumination Inadequate Guards/Barrier Equipment/Workstation Design Poor Housekeeping Equipment Failure Hazardous Materials Defective Tools/Equipment/Vehicle Other What ACTION or INACTION contributed to the incident? * Not Applicable Failure to Make Secure Improper Lifting Used Equipment Improperly Operating Procedure Deviation Horseplay/Distractive Active Nullified Safety/Control Devices Servicing Equipment In Motion Used Defective Equipment Improper Technique Unauthorized Actions Improper Position Unsafe Act of Another Staff Running/Rushing/Acting In Haste Failure to Use PPE Improper Loading Operating At Improper Speed Used Wrong Tool/Equipment Under Influence Drugs/Alcohol Failure to Warn/Signal Other CHECK ALL UNDERLYING OR ROOT CAUSES THAT APPLY What caused or influenced the substandard conditions or behaviors? * Lack of Proper Job Procedures Inadequate Job Training Methods Inadequate Maintenance Standards Poor Work Design Lack of Communication Between Staff Inadequate Cleaning Inadequate Preventive Maintenance Inadequate Job Instructions Inadequate Supervision Unsafe Design or Construction Inadequate Purchasing Standards Improper Extension of Service Life Inadequate Environmental Controls Inadequate Enforcement of Work Standards Inadequate Tools Improper Layout or Design Poor Work Practice Lack of Skill Improper Planning Inadequate Capacity Other CHECK ALL ACTIONS NECESSARY TO CORRECT THE DIRECT AND ROOT CAUSES What corrective actions have been taken or are needed to prevent a recurrence? * Task Analysis/Procedure Revision Reinstruction of Employees Eliminate Congestion Task Analysis to Be Completed Improve Design/Construction Improve Illumination Improve Clean-Up Procedures Improve Storage/Arrangement Improve/Change Work Method Install/Revise Guards/Devices Job Reassignment of Employees Mandatory Pre-Job Instructions Repair/Replace Equipment Rotation of Employee Identify/Improve PPE Improve Enforcement Use Other Materials/Suppliers Improve Ventilation Other Recommended corrective actions or preventive measures to be taken. Action Item 1 Action Item Person Responsible Target Date Date Complete Action Item 2 Action Item Person Responsible Target Date Date Complete Action Item 3 Action Item Person Responsible Target Date Date Complete Action Item 4 Action Item Person Responsible Target Date Date Complete Investigation Review (initial after reviewing the findings of the investigation) Supervisor Name Initials Review Date Comments Manager Name Initials Review Date Comments Site/Regional Manager Name Initials Review Date Comments Safety Representative Name Initials Review Date Comments Directory/Deputy Name Initials Review Date Comments
