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INCIDENT INVESTIGATION REPORT
DEPARTMENT:
LOCATION OF INCIDENT:
DATE OF INCIDENT:
TIME:
DATE REPORTED:
TIME:
INJURY OR ILLNESS
OTHER INCIDENTS
INJURED’S NAME:
OCCUPATION:
AREA OF INJURY/ILLNESS:
NATURE OF INJURY/ILLNESS:
TIME ON TASK:
PERSON REPORTING INCIDENT:
OBJECT/EQUIPMENT/SUBSTANCE
INVOLVED:
PERSON WITH MOST CONTROL OF
OCCUPATION:
PROPERTY DAMAGE
PROPERTY DAMAGE TO:
NATURE OF DAMAGE:
COST ESTIMATED
ACTUAL
TYPE OF CONTACT:
CONTACT WITH:
STRUCK AGAINST
SLIP/TRIP
OVEREXERTION
ELECTRICITY
TOXIC SUBSTANCE
STRUCK BY
FALL ON SAME LEVEL
REPETITION
HEAT/COLD
CORROSIVES
CAUGHT IN/ON
FALL TO BELOW
BODILY REACTION
NOISE
LASER, RADIATION
RISK
EVALUATION OF LOSS POTENTIAL IF NOT CORRECTED:
SEVERITY: SEVERE SERIOUS MINIMAL
PROBABILITY: HIGH MEDIUM LOW
DESCRIPTION
DESCRIBE HOW THE EVENT OCCURRED:
IS THERE A WRITTEN SAFE WORK PROCEDURE OR JOB HAZARD ANALYSIS FOR THIS JOB/TASK?
YES NO
HAS THIS WORKER RECEIVED TRAINING RELEVANT TO THE ACTIVITY INVOLVED?
YES NO
WITNESSES TO THE INCIDENT (NAME AND CONTACT NUMBER):