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Incident Investigation Form

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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

Examples: 01:00am, 11:30pm

Additional Information

Allowed file types: jpg, jpeg, png, txt, pdf, doc, docx

Initial Investigator

Examples: 01:00am, 11:30pm

CHECK ALL DIRECT CAUSES THAT APPLY


CHECK ALL UNDERLYING OR ROOT CAUSES THAT APPLY


CHECK ALL ACTIONS NECESSARY TO CORRECT THE DIRECT AND ROOT CAUSES


Recommended corrective actions or preventive measures to be taken.

Action Item 1


Action Item 2


Action Item 3


Action Item 4


Investigation Review (initial after reviewing the findings of the investigation)

Supervisor


Manager


Site/Regional Manager


Safety Representative


Directory/Deputy