Incident Investigation Report

Incident Investigation Report

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Employee's Information

Employee's First Name*

Employee's Last Name*

Employee's Email Address*

Employee 10-Digit ID*

Employee Occupation*

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If "Other" was selected, provide title:

Gender of Employee*

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Supervisor's Information

Supervisor's First Name*

Supervisor's Last Name*

Supervisor's Email Address*

Incident Overview

Date of Incident*

Time of Incident*

Hour : Minute (AM/PM)

MRI Submission Date*

What part of the employee's shift?*

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(A) If "Other" was selected, please explain:

Building Location of Event*

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If "Other" was selected, please explain:

Description of Location*

Please be specific in your description including building names, landmarks, etc.

If "Illness" was selected, please describe:

What part of the body was injured?*

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(B) If "Other" was selected, please explain:

Were there any witnesses?*

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(A) If "Yes" was selected:

Nature of Injury*

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* If "Other" was selected, please explain:*

Was Broadspire called?*

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Treating Physician's Name

Name of Hospital

Description of the Accident/Incident*

In your description, include the following information:

Describe what the employee was doing at the time of the event.
What equipment/tools were being used.
What caused the event.
Working/environmental conditions.

Unsafe Acts & Work Conditions

Unsafe Work Conditions Present*

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Why were the unsafe conditions present?*

Unsafe Acts by People*

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(D) If "Other" was selected, please explain:

Why did the unsafe acts occur?*

Unsafe Act Motivators*

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(B) If "Yes" was selected, please explain:

Were the unsafe acts or conditions reported prior to the incident?*

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Have there been similar incidents or near misses prior to this one?*

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(D) If "Yes" was selected, please include:

Jobsite Safety

Personal Protective Equipment (PPE)*

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(E) If "Other" was selected, please explain:

Job Hazard Analysis (JHA)*

Was a Job Hazard Analysis (JHA) form provided?

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Were safety regulations in place and implemented?*

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* If "No" was selected, please explain:

Preventative Actions & Lessons Learned

What immediate corrective action(s) took place in response to this event?*

What are the recommended preventative actions that will take place to prevent reoccurrence?*

Post-Analysis*

What were the lessons learned from this event?

Refresher Training*

Select

(E) If "Yes" was selected:

Additional Information

Include any additional information you'd like to provide:

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