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Incident Investigation Form
PARTICULARS OF INCIDENT
Incident Date:
*
Time:
*
AM
PM
Location:
*
Company Premises
Job Site
Supervisor:
Date Reported:
*
REPORTING THE INCIDENT
First Name:
*
Last Name:
*
Employee Id:
*
Age:
Address:
Phone Number:
*
Job title or occupation:
*
Hire Date:
How long at this assignment:
What was employee doing when incident occurred? What machine or tool? What operation?
Is an injury alleged to have occurred in connection with the reported incident?
Yes
No
If YES, who was allegedly injured?
Has injury been confirmed?
Yes
No
Cannot Confirm
If injury has NOT been confirmed, explain why?
Type of injury alleged:
Strain/sprain
Amputation
Laceration/cut
Bruising
Internal
Fracture
Dislocation
Chemical reaction
Scratch/abrasion
Foreign body
Burn scald
Other (specify)
Part of body:
Remarks:
Has medical examination & treatment by a physician been rendered?
Yes
No
If YES, where, by whom and when:
If YES, What was physician’s initial diagnosis and treatment?
If YES, What was physician’s initial duty determination?
Return to duty
Duty with restrictions
Full release from duty
What treatment, if any, was provided?
Did the physician write one or more prescriptions relating to the examination?
Yes
No
N/A
If YES, what were the prescriptions (if known):
Was a post-accident drug screen rendered in accordance with company drug-free workplace policy?
Yes
No
Where and by whom was the drug screen sample collected?
What was the method of collection?
Urine
Blood
Other
DAMAGED PROPERTY
Property / material damaged:
Nature of damage:
Object/substance inflicting damage:
THE INCIDENT AS REPORTED
DESCRIPTION Describe what reportedly happened. Use of drawings, photos and diagrams may be included.
1. State the conditions prior to the event. This includes status of task performed or equipment used.
2. What was the employee’s work assignment prior to the event?
3. What work controls (procedures, work order, clearance, etc.) applied to the work assignment?
4. List any noted equipment problems or inadequacies both before and after the event?
5. Explain if there are any procedure or work instruction deficiencies associated with the event.
6. What do you believe caused this event?
7. What recommendations do you have to prevent reoccurrence of this event?
8. List others present or involved with this event.
WITNESSES List name of any witnesses here. Attach individual witness statements as obtained.
HOW SERIOUS COULD IT HAVE BEEN?
Serious
Very serious
Not Serious
WHAT IS THE CHANCE OF IT HAPPENING AGAIN?
Frequent
Occasional
Rare
PREVENTION
What specific action has or will be taken to prevent a recurrence? Check items already actioned. Use additional pages if required.
By whom
When
Report prepared & submitted by:
*
With review by:
Date:
Witness Statement:
Witness Signature:
*
Clear signature
Date:
Upload Files :
(Upload only pdf or image file)
Foreman Email:
Other Email:
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