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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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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.
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