Incident Investigation

1 — Incident Details

Company

Report / Case #

Date of Incident

Time of Incident

Date Reported

Job / Project #

Location / Work Site

Reported By

Supervisor

Investigated By

Incident Classification (select all that apply)

Potential Severity

Reported to Regulator (OHS)?

2 — Equipment Involved

Equipment Type

Make / Model

Unit # / Serial

Operator

Equipment / Mechanical Notes

3 — People Involved & Witnesses

0 listed

List each injured / involved person and every witness. Add their account of what happened.

4 — Injury / Damage / Loss

Injured Person

Body Part(s) Affected

Nature of Injury

Treatment Given

Est. Property / Equipment Damage ($)

Equipment Downtime

Environmental Release?

Property / Environmental Damage Description

5 — Immediate Actions Taken

Describe Immediate Actions & Controls Put in Place

6 — Sequence of Events

What Happened — Step by Step

Weather / Lighting

Ground / Surface Conditions

7 — Root Cause Analysis

0 factors

Work backward with the 5 Whys, then tick every contributing factor that applied. The goal is the underlying cause — not blame.

5 Whys

Root Cause (conclusion)

Contributing Factors

Other Contributing Factors (write-in)

8 — Corrective Actions

0 actions

Every action needs an owner and a due date so it can be tracked to completion.

Corrective Action

Type

Responsible

Due Date

Status

9 — Review & Sign-Off

Investigator Signature

Sign Here

Name & date below

Manager / Reviewer Signature

Sign Here

Name & date below

Investigator Name

Date Signed

Reviewer Name

Date Reviewed

Rock Solid