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Incident Investigation Report

This document is an Incident Investigation Report form used to document workplace incidents, including details about the injured employee, the nature of the injury, and the circumstances surrounding the incident. It includes sections for describing unsafe conditions, acts, and suggestions for preventing future incidents. The report must be completed by a designated individual and reviewed by a supervisor or team member.

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kaungzayar1706
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106 views3 pages

Incident Investigation Report

This document is an Incident Investigation Report form used to document workplace incidents, including details about the injured employee, the nature of the injury, and the circumstances surrounding the incident. It includes sections for describing unsafe conditions, acts, and suggestions for preventing future incidents. The report must be completed by a designated individual and reviewed by a supervisor or team member.

Uploaded by

kaungzayar1706
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Safety Form:

Incident Investigation Report

This is a report of a:  Death  Lost Time  Medical Treatment  First Aid Only  Near Miss

This report is made by:


Date of incident:
 Employee  Supervisor  Team  Other

Step 1: Injured employee (complete this part for each injured employee)

Name: Sex:  Male  Female Age:


Department: Job title at time of incident: install curtain wall frame
Part of body affected: (shade all that apply) Nature of injury: (most This employee works:
serious one)  Regular full time
 Abrasion, scrapes  Regular part time
 Amputation  Seasonal
 Broken bone  Temporary
 Bruise Months with
 Burn (heat) this employer -2 Months
 Burn (chemical) Months doing
 Concussion (to the this job: 2-Months
head)
 Crushing Injury
 Cut, laceration,
puncture
 Hernia
 Illness
 Sprain, strain
 Damage to a body
system:
 Other

Step 2: Describe the incident

Exact location of the incident: Exact time:

What part of employee’s workday?  Entering work Leaving work  Doing normal work
activities  During meal period  During break  Working overtime  Other

Names of witnesses (if any):

26 October 2023 Incident Investigation Report 1/5


Number of Written witness statements: Photographs: Maps / drawings:
attachments:
1

What personal protective equipment was being used (if any)?

Describe, step-by-step the events that led up to the injury. Include names of any machines, parts, objects,
tools, materials and other important details.

Step 3: Why did the incident happen?

Unsafe workplace conditions: (Check all that apply) Unsafe acts by people: (Check all that apply)
 Inadequate guard  Operating without permission
 Unguarded hazard  Operating at unsafe speed
 Safety device is defective  Servicing equipment that has power to it
 Tool or equipment defective  Making a safety device inoperative
 Workstation layout is hazardous  Using defective equipment
 Unsafe lighting  Using equipment in an unapproved way
 Unsafe ventilation  Unsafe lifting
 Lack of needed personal protective equipment  Taking an unsafe position or posture
 Lack of appropriate equipment / tools  Distraction, teasing, horseplay
 Unsafe clothing  Failure to wear personal protective equipment
 No training or insufficient training  Failure to use the available equipment / tools
 Other:  Other:

Why did the unsafe conditions exist?

Why did the unsafe acts occur?

Is there a reward (such as “the job can be done more quickly”, or “the product is less likely to be damaged”)
that may have encouraged the unsafe conditions or acts?  Yes  No If
yes, describe:

Were the unsafe acts or conditions reported prior to the incident?  Yes  No

Have there been similar incidents or near misses prior to this one?  Yes  No

26 October Accident Investigation 2/


Step 4: How can future incidents be prevented?
What changes do you suggest to prevent this incident from happening again?

 Stop this activity  Guard the hazard  Train the employee(s)  Train the supervisor(s)

 Redesign task steps  Redesign work station  Write a new policy/rule  Enforce existing policy

 Routinely inspect for the hazard  Personal Protective Equipment  Other:

What should be (or has been) done to carry out the suggestion(s) checked above?

Step 5: Who completed and reviewed this form?


Written by: Title:

Department: Date:
Names of investigation team members:

Reviewed by: Title:

Date:

26 October Accident Investigation 3/

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