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Inccident Investigation Form v5.0

This 3 page incident report document contains sections for recording details of an incident or near miss event including: type of event, harm caused, employee details, witness details, investigation required, investigation level, and reported by. Page 1 requests event details, injuries/ill health effects, and investigation details such as activities, equipment, working conditions, competence, and causes. Page 2 focuses on causes and recommended risk controls. Page 3 documents the investigation team members, signatures accepting the report, and communication of findings.

Uploaded by

ahmed
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291 views4 pages

Inccident Investigation Form v5.0

This 3 page incident report document contains sections for recording details of an incident or near miss event including: type of event, harm caused, employee details, witness details, investigation required, investigation level, and reported by. Page 1 requests event details, injuries/ill health effects, and investigation details such as activities, equipment, working conditions, competence, and causes. Page 2 focuses on causes and recommended risk controls. Page 3 documents the investigation team members, signatures accepting the report, and communication of findings.

Uploaded by

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

Incident report Date/time of event

Company Department Site name

Type of event Injury Ill health Near miss

Harm (or potential for harm) Fatal or major Serious Minor Damage to property only
Employee involved in the event Name Address
Position
Contact number

Brief description of event


(Details of what happened, when, where, and
emergency action taken)

Details of witness(es), if any


(Name, position, contact number, etc.)

Investigation required Yes Reportable Yes


Date/time reported
Investigation level High Medium Low Minimal
Priority Entry in accident book Yes
Leader of investigation Date/time entered

Reported by Position Date Signature


Incident investigation report Page 1 of 3

Company Department Site name

Event details Employee(s) involved Location


Date
Time

Injuries or ill health effects, if any

Investigation details
Include details such as
- overview of the event
- activities being performed
- equipment used
- working conditions
- safety of working procedures
- maintenance
- competence of people involved
- workplace layout
- safety equipment used
- any other conditions which may have influenced the
event
Incident investigation report Page 2 of 3

Causes of the event


Immediate causes Underlying causes Root causes

Which risk control measures should be implemented to prevent recurrence?


Risk control Planned completion date Actual completion date Manager responsible

Which risk assessments and safe working procedures need to be reviewed and updated?
Risk control Planned completion date Actual completion date Manager responsible
Incident investigation report Page 3 of 3

Are there any further details that


should be mentioned?

Members of the investigation team Name Position Name Position

Signed on behalf of the investigation team


Name Position Date Signature

Report accepted by
Name Position Date Signature

The findings of this investigation need to be communicated to the following people


Name Position Date Signature

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