INSERT YOUR COMPANY NAME AND LOGO HERE

INCIDENT INVESTIGATION FORM

Customize the sheet to reflect your workplace.

DATE:
Section A: Investigator
Name Title
Section B: Incident Description/Injury Information

Name Injured Employee Age

Employees Job Title

Type of employment:
Fulltime Parttime Temporary Seasonal Other
Length of time with the company: Length of time in current position:
Description and severity of injury:
Date and time of incident:

Location of incident:
Detailed description of incident. Include relevant events leading up to, during, and after the
incident, and add as many pages as you need to accurately describe the incident.
Description of incident from eye witnesses, including relevant events leading up to,
during, and after the incident. Include names of persons interviewed, job titles, date, and time of
interviews.
Description of incident from additional employees with knowledge, including relevant
events leading up to, during, and after the incident. Include names of persons interviewed,
job titles, date, and time of interviews.

Section C: Identify the Root Cause: What caused or allowed the incident to happen?
Add as many pages as you need to accurately describe what caused the incident.
The Root Cause is the underlying reason the incident occurred and needs to be addressed
to prevent future incidents.
If safety procedures were not being followed, why were they not being
followed?
If a machine was faulty or a safety device failed, why did it fail?
Contributing factors can come from many issues: equipment/machinery, tools,
procedures, training or lack of training, and work environment. As you identify which,
determine why these factors were not addressed before the incident.
Section D: Recommended Corrective Actions to Prevent Future Incidents
(add as many pages as you need to accurately describe)

Section E: Corrective Actions Taken/Root Cause Addressed

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(add as many pages as you need to accurately describe)