Lumiform / Templates / Incident Investigation Template

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.

★ ★ ★ ★ ★

Rated 5/5 stars on Capterra

Say goodbye to paper checklists!

Lumiform enables you to conduct digital inspections via app easier than ever before

Cut inspection time by 50%
Uncover more issues and solve them 4x faster
Select from over 5,000 expert-proofed templates

Digitalize this paper form now

Cut inspection time by 50%
Uncover more issues and solve them 4x faster
Select from over 4000 expert-proofed templates

★ ★ ★ ★ ★

Rated 5/5 stars on Capterra

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:

Previous template

Next template

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.