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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 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:
Share this template:

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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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