Easy assignments - Need in 6-8 Hours.Safety Management Systems
Incident Investigation Report Report Tracking No. 20___-_____
| Part 1: Employee Information | |||
| Name of Employee | Employee Number | ||
| Company | Date of Incident | ||
| Department/ Classification | Time of Incident | ||
| Age of Employee | Years of Experience | ||
| Part 2: Incident Information | |||
| Type of Injury | |||
| Part of Body | Medical Attention | YES NO | |
| Severity of Injury | Circle Below: Near Miss/Report Only First Aid OSHA Lost Time* Fatality Property Damage | * If Lost Time - Days Lost | |
| Restricted Days | |||
| Medical Follow-up | YES NO | ||
| Additional Information | Date(s) of Medical Follow-up | ||
* If additional personnel were affected copy this sheet and attach.
| Executive Summary |
Incident Investigation Team Members:
Executive/Management Sponsor:
Safety Professional:
SME:
Union Rep:
Additional Name(s)/Title:
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| Executive / Manager Signature | Date | ||
| Use Proper Analysis Tool Kit (at a minimum, circle all used in initial investigation ) | |||
| Digital / Video Camera | Sample Bottle / tags / plastic bags / tape | ||
| Procedures / drawings / Manuals / MSDS | Direct Reading Instruments i.e. gas detector, hot stick, etc. | ||
| Notebooks/Graph paper | Flashlight & batteries | ||
| ruler/tape measure | Barricades, ropes/tape | ||
| Other: | |||
| Part 3: Incident Information | |||
| What happened? Sequence of Events (use separate sheet for all involved and witnesses) | |||
| When did it happen? | |||
| Where did the incident occur? | |||
| Who was involved? | |||
| How did it happen? | |||
| Why did it happen? | |||
| How can we keep this from happening again? | |||
| What tools/equipment was involved? | |||
| Were there witnesses? (document their statement on separate sheet and attach) | |||
| Was this a routine evolution? | |||
| Have you been trained on this task? If so how frequently? | |||
| Process/Procedure Involved | |||
| Has this occurred prior? Yes, was it documented? (list incident tracking number(s) below) NO | |||
Diagram of area
Cause and Recommendations derived from information gathered from investigation
| Direct Cause of Incident: | ||||
| Contributing Cause(s) of Incident: | ||||
| Final Recommendation(s) Summary: | ||||
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1 | Recommendation:
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| Actions - | Due Date | Owner | Status |
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| 1B |
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2 | Recommendations:
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| Actions - | Due Date | Owner | Status |
| 2A |
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| 2B |
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| 3 | Recommendations:
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| Actions - | Due Date | Owner | Status |
| 3A |
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| 3B |
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4 | Recommendations:
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| Actions - | Due Date | Owner | Status |
| 4A |
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| 4B |
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List additional documentation
| (Example: Attachment 1 – Photo 1, or MSDS, etc.) |
| Additional Information / Follow-up Information |
| Continue with additional sheets if necessary |
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