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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

      Incident Description

      Provide a full description of the surroundings of the location and the individuals involved.
      Describe the sequence in order and when they took place.
      Include the affected body part(s) and injury type or indicate no injury occurred.

      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