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Incident Investigation Template

Use this incident investigation template to do a root cause analysis for an incident or near-miss at a workplace. This template can be applied to help find important facts and general background information of the event.
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Incident Investigation Template

Audit

Incident Details

List the names of people involved in the incident:
What happened?
What task was performed at the moment of the incident
Attach photo proof of incident:
Attach photo evidence of the surrounding environment:
People in the incident investigation team:

Contributing Factors

Choose all the relevant contributing factors for each of the sections below.
Environmental factors
Equipment/ Materials factors
Work systems factors
People factors
Attach photo proof of any contributing factors:

Sign off

Person involved in the incident:
Name and signature of the supervisor:
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