Incident Investigation Report
Issue Date : 02-06-
Doc# SK-FM-017-02-00 Issue # 01 Rev. Date: - Page 1 of 2
2023
a) This form to be completed for all job-related injuries or illnesses – regardless of extent.
b) Must be completed by supervisor within 24 hours of incident.
Name ________________________________________________________________ Job Tile _________________________________
First Middle Last
AM AM
Date of Injury: Hour: PM Time Left Work: PM Date of Birth:
Department Name Name of Supervisor Date Reported to Supervisor
Exact Location of Accident: Name of Witness:
Describe Accident (What was injured worker doing; what objects, machines o materials were involved):
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Regular Days Off Working Shift AM AM
PM to PM
Employee Signature: ________________________________________________________ Date: ___________________________
ACTION BODY PART INJURED NATURE OF INJURY
FIRST AID CASE ONLY HEAD FACE EYE ABRASION LACERATION PUNCTURE
REQUIRED DOCTOR’S CARE NECK BACK CHEST BRUISE FRACTURE BURN
HOSPITALIZED ARM HAND FINGER SPRAIN/STRAIN FOREIGN BODY POISON OAK
OSHA NOTIFIED LEG KNEE ANKLE COLD INJURY HEAT NJURY DEMATITIS
TIME LOSS FOOT TOE LOSS OF OCCUPATIONAL
NO INJURY/NEAR MISS OTHER _____________________________________ CONCIOUSNESS ILLNESS
OTHER ________________________________________
Additional Note:
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Incident Investigation Report
Issue Date : 02-06-
Doc# SK-FM-017-02-00 Issue # 01 Rev. Date: - Page 2 of 2
2023
HSE INCHARGE INVESTIGATION OF CAUSE (CHECK ONE OR MORE)
Did you personally view the incident site? Yes No Employee Category: Faculty Staff Visitor
UNSAFE ACTS UNSAFE CONDITIONS
OPERATING WITHOUT HORSEPLAY IMPROPERLY GUARDED INADEQUATE WARNING
AUTHORITY EQUIPMENT OR MACHINE SYSTEM
FAILURE TO WARN OTHERS FAILURE TO USE PERSONAL DEFECTIVE TOOL OR HAZARDOUS STORAGE OR
PROTECTIVE DEVICES EQUIPMENT ARRANGEMENT
OPERATING OR WORKING AT FAILURE OT OBSERVE SAFETY POOR HOUSEKEEPING HAZARDOUS DRESS OR
UNSAFE SPEED REGULATIONS APPAREL
MAKING SAFETY DEVICES LACK OF TRAINING OR IMPROPER LIGHTING HAZARDOUS WORK
INOPERATIVE KNOWLEDGE PROCEDURE
FAILURE TO SECURE OBJECTS PREVENTABLE VEHICLE IMPROPER VENTILATION HAZARDOUES WEATHER OR
ACCIDENT (DUST, FUMES, ETC.) ENVIRONMENT
USING UNSAFE EQUIPMENT SLIPS AND FALLS UNSAFE DESIGN OR CONTACT WITH POISONOUS
OR EQUIPMENT UNSAFELY CONSTRUCTION PLANTS, INSECTS, TOXIC
UNSAFE LOADING, MIXING, FAILURE TO LOCK OUT/TAG SLIPPERY OR OTHER UNSAFE CHEMICALS, SKIN IRRITANTS,
CARRYING OUT SURFACE BITES, ECT.
TAKING UNSAFE POSITION OR OTHER: OTHER:
POSTURE _________________________________ _________________________________
REASONS FOR UNSAFE ACT (Must be completed by HSE Incharge)
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REASONS FOR UNSAFE CONDITION (Must be completed by HSE Incharge)
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WHAT PRACTICAL CORRECTIVE ACTION WILL BE TAKEN BY HSE INCHARGE TO PREVENT RECURRENCE? (Must be
completed by HSE Incharge.) Note: The wording “be more careful” is unacceptable, as it does not present a viable
solution. If the cause is properly identified, there should be several solutions.
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HSE INCHARGE SIGNATURE _______________________________________________ DATE ___________________________
