INCIDENT INVESTIGATION
REPORT FORM
THIS FORM SERVES TO DOCUMENT select all that apply
DAMAGE
TO ER / CLINIC FIRST AID
LOST TIME NEAR MISS
PROPERT TREATMENT ONLY
Y
DATE OF
REPORT COMPLETED BY Name and Title DATE OF REPORT
INCIDENT
INJURED EMPLOYEE INFORMATION
EMPLOYEE NAME AGE DATE OF BIRTH
DEPARTMENT
DESIGNATION AT TIME OF INCIDENT
NATURE OF INJURY select all that apply
Abrasion,
Amputation Broken Bone Bruise Burn (heat)
scrapes
Burn Crushing
Concussion Cut, laceration, puncture
(chemical) Injury
Hernia Illness Sprain, strain Damage to body system
Other,
describe:
PART OF BODY AFFECTED shade all that
DESCRIPTION OF INJURY apply
Page 1 of 5
INCIDENT INVESTIGATION
REPORT FORM
INCIDENT DETAILS
LOCATION DATE OF INCIDENT TIME
During what part of the employee’s workday did the incident occur?
WITNESSES if any
PROTECTIVE EQUIPMENT List any personal protective equipment used at the time of the incident.
INCIDENT DESCRIPTION Describe tasks being performed and sequence of events. Attach additional
pages as necessary.
ATTACHMENTS List anything to be submitted with this report (forms, witness statements, photographs,
maps, drawings, etc.)
Page 2 of 5
SUPERVISOR’S INCIDENT
INVESTIGATION
REPORT FORM
WHY DID THE INCIDENT OCCUR?
UNSAFE WORKPLACE CONDITIONS select all that
apply UNSAFE ACTS BY PEOPLE select all that apply
Inadequate guard Operating without permissions
Unguarded hazard Operating at unsafe speed
Safety device is defective Servicing equipment that has power to it
Tool or equipment is 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 necessary personal protective
Taking an unsafe position or posture
equipment
Lack of appropriate equipment / tools Distraction, teasing, horseplay
Failure to wear personal protective
Unsafe clothing
equipment
No training or insufficient training Failure to use the available equipment / tools
Other; Describe below: Other; Describe below:
Why did the unsafe conditions exist?
Why did the unsafe acts occur?
Is there a workplace culture, norm, or expectation that may have encouraged YE
NO
the unsafe conditions or acts? S
If yes,
describe:
YE
Were the unsafe acts or conditions reported prior to the incident? NO
S
YE
Have there been similar incidents or near misses prior to this one? NO
S
F-QMD-019 Page 3 of 5
Rev.0;2/5/20
INCIDENT INVESTIGATION
REPORT FORM
HOW CAN FUTURE INCIDENTS BE PREVENTED?
What changes do you suggest to prevent this incident / near miss from happening again? select all
that apply
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
Personal protective equipment
hazard
Other; Describe below:
What should be (or has been) done to carry out the suggestion(s) selected above?
CORRECTIVE ACTION PLAN SHORT-TERM ACTION PLAN LONG-TERM ACTION PLAN
Page 4 of 5
INCIDENT INVESTIGATION
REPORT FORM
REPORT DETAILS
REPORT WRITTEN BY
NAME DESIGNATION
DEPARTMENT DATE
REPORT REVIEWED BY
NAME DESIGNATION
DEPARTMENT DATE
INVESTIGATION TEAM MEMBERS
NAME DESIGNATION
REPORT SUBMITTED BY
NAME SIGNATURE DATE
REPORT RECEIVED BY
NAME SIGNATURE DATE
Page 5 of 5
