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Incident Investigation Report Template

Use this template for an accident report to investigate accidents in detail. Analyze the causes of an accident or near-accident in the workplace. This digital form for the accident report is used by supervisors to collect facts about an incident.

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Incident Investigation Report Template

Audit

Location of incident

Job Number:

Date of occurrence:

Date reported:

Contractor?

Type of Incident. Select all that apply.

Near Miss?

Was First aid required?

Was Medical Aid necessary?

Restricted Work?

Occupational Illness?

Lost Time Injury?

A Fire or an Explosion?

Failure of Equipment?

Property Damage?

Material or Business Loss?

Motor Vehicle Accident?

Threats?

Other

Injury

What type of injury?

What body part is injured?

Was a follow-up treatment necessary?

Person Involved

Employee's name

Date of Birth

Address

SIN Number

Health Care Number

Description

Specifically describe how the incident occurred.

Witnesses

Include names and phone numbers of all witnesses to the incident. Attach witness statements.

Analysis

What immediate causes, failures to act, and conditions contributed directly to the accident?

What basic causes are the contributing factors? (Job factors, personal factors)

Prevention

What action or recommendations are to prevent recurrence? When? And action by?

Potential of Frequency

Frequent

Probable

Occasional

Remote

Improbable

Severity of Incident

Catastrophic

Critical

Moderate

Minor

Costs of Incident

Estimated:

Actual:

Conclusion

Further comments

Investigated by:

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Please note that this checklist template is a hypothetical appuses-hero example and provides only standard information. The template does not aim to replace, among other things, workplace, health and safety advice, medical advice, diagnosis or treatment, or any other applicable law. You should seek your professional advice to determine whether the use of such a checklist is appropriate in your workplace or jurisdiction.