Template Information
Collect evidence, find root causes and investigate incidents, accidents and injuries. create a comprehensive incident investigation report.
Template Questions
- Date & Time of Incident Date
- Location of Incident Address
- Incident Details
- Site / Project Name
- Incident Type (select all that apply)
- Name of on-duty supervisor at time of incident?
- Describe what happened. Please be detailed but state only facts.
- Incident Summary
- Build a timeline of key incident events below
- Event Date / Time Date
- Event Description
- What were the weather / environmental conditions at the time of the incident?
- Which of the following do you need to attach to this report to accuractly document this incident?
- Please log all relevant evidence below
- Evidence Description
- Evidence ID number (if applicable)
- Evidence and Attachments
- Photos of evidence (if applicable)
- Please detail any further information regarding this evidence (if applicable)
- Please log all relevant vehicle details below
- Vehicle Make
- Vehicle Model
- Vehicle Registration
- Driver (if applicable)
- Photos of equipment (if applicable)
- Please detail any further information regarding this vehicle (if applicable)
- Please log all relevant damage details below
- Damage description
- ID number (if applicable)
- Photos of damage (if applicable)
- Please detail any further information regarding this damage (if applicable)
- Please log all relevant details of other items below
- Item description
- Photos of item (if applicable)
- Please detail any further information regarding this item (if applicable)
- Please log all relevant equipment details below
- Equipment Make
- Equipment Model
- Equipment ID number (if applicable)
- Please detail any further information regarding this equipment (if applicable)
- Please document all people involved in this incident
- Full Name
- ID number
- Contact phone number
- What is this person's relation to the incident? (select all that apply)
- Please describe this person's involvement with the incident, including all relevant information
- Attach any relevant photos regarding this person
- Person
- Type of injury or illness? (select all that apply)
- Parts of body affected? (select all that apply)
- Describe this injury or illness
- What was the cause of this injury or illness?
- Corrective Actions
- What were the contributing factors to this incident occurring? (select all that apply)
- A Root Cause Analysis (RCA) is the process of determining the cause of an incident. It requires consi
- Root Cause Analysis / Contributing Factors
- Sign Off
- Name & Signature of Investigator