Incident Investigation Action Plan



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General Date of investigation: / / eduSafe/CASES 21 reference number (attach hardcopy of report): Date of incident/near miss occurrence: / / Area where incident/ near miss occurred: Has a similar incident/near miss occurred previously (circle): Yes No Investigation team Workplace Manager (investigation lead): Management OHS Nominee: Health and Safety Representative: Other: Other: Other: Witness details Name: Position: Contact Details: Telephone: Email: Name: Position: Contact Details: Telephone: Email: Description of event Who was involved (please circle): Employee Student Volunteer Visitor Contractor Member of public Briefly describe what happened at the time of the incident/near miss..




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