Incident Investigation Report

Instructions: Complete this form as soon as possible after an incident that results in serious injury or illness.

(Optional: Use to investigate a minor injury or near miss that could have resulted in a serious injury or illness.)

This is a report of a:

Date of Incident

Date

This report is made by:

EmployeeSupervisorTeamOther

Full Name:*

First NameLast Name

Gender:

MaleFemale

Age

Department:

Job title at time of incident:

Part of body affected: (shade all that apply)

Nature of injury: (mostserious one)

This employee works:

Regular full timeRegular part timeSeasonalTemporary

Months with this employer:

Months doingthis job:

Exact location of the incident:

Exact Date and Time:

DateHourMinutesAM/PM Option

What part of employee’s workday?

Names of witnesses (if any):

Attachments (Upload all that applies)

Browse Files

Written witness statements/ Photographs/ Maps / drawings:

What personal protective equipment was being used (if any)?

Describe, step-by-step the events that led up to the injury. Include names of any machines, parts, objects, tools, materialsand other important details.

Incident Investigation Report

Step 1: Injured employee

Step 2: Describe the incident

Step 3: Why did the incident happen?

Step 4: How can future incidents be prevented?

Step 5: Who completed and reviewed this form?