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Incident Investigation Report
Complete within 24 hours of any workplace incident.
Original PDF form also available
Download PDF
Incident Details
Date of Incident
*
Time of Incident
Location
*
Incident Type
*
Select type
Near Miss
First Aid
Recordable Injury
Lost Time Injury
Property Damage
Environmental
Other
Department / Work Area
Supervisor Name
*
Supervisor Phone
Involved Person
Full Name
*
Job Title
Phone
Date of Hire
Time on This Job / Task
Injury / Damage
Nature of Injury or Damage
*
Body Part Affected
Medical Treatment
Select
None
First Aid on site
Clinic / urgent care
Emergency room
Hospitalized
Property / Equipment Damaged
Estimated Cost of Damage
Witnesses
Witness 1 — Name & Phone
Witness 2 — Name & Phone
Incident Description
*
Root Cause & Corrective Actions
Immediate Cause
Root / Contributing Cause
Corrective Actions
Due Date
Assigned To
Reported By
Name
*
Title
Phone
*
Email
Submit Investigation Report
