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
