Incident Investigation Form
Use this form to investigate an incident that has happened! PLEASE BE AS DESCRIPTIVE AS POSSIBLE - the more information we take down, the safer we can be next time!
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이메일 *
WHO is investigating this incident? *
I.e. WHO are YOU? Who is assisting you?
What was the incident that happened? *
I.e. What incident is this incident in response to? BE BRIEF...
WHO was affected by the incident? *
I.e. John Smith
HOW were they affected by the incident? *
I.e. Hand received a significant cut.
What training did they have in regards to the task that was being undertaken at the time? *
I.e. How many years had they been doing this task? Had they had formal training, etc.?
HOW did the incident occur directly? *
I.e. Hand made contact with sharp edge of exposed metal on dishwasher and cut occurred?
WHAT was done directly following the incident? *
I.e. What were the corrective actions - First Aid? Reported to site supervisor? Went to emergency department? Site closed down for formal investigation?
What WILL BE DONE from here, to ensure that the worker is treated appropriately and is back to work (including under reduced duties) as soon as possible?
What were the 'costs' of this incident?
i.e. How many days / hours were taken off, was any equipment needed to be replaced or fixed because of this? Were car repairs required? Try to approximate the cost in either $ or hours. Remember that it is better to have a worker come back to work with reduced duties, rather than stay at home!
WHAT could have been done to prevent this from happening? *
i.e. Protective gloves could have been worn. Edge Could have been taped. Worker could have been less fatigued and been more observant of exposed sharp edges? Site could have not caused stress?
WHY was this not done? *
i.e. Gloves were left in van? Tape was lost at previous job? Worker was being pressed for time by site staff to complete the task faster, and had been working for over 9 hours already?
WHAT CAN AND WILL BE DONE IN FUTURE to PREVENT this from happening again? *
HOW CAN WE MAKE THIS SAFE TO DO? I.e. Preventative actions - Glove clips to be provided? Discussion had with worker regarding use of PPE and to always carry tape? Discussion with worker regarding noticing signs of fatigue and taking breaks if needed? Investigation into safer operation to happen? Site advised to stop harassing worker? Advice given to ALL WORKERS to carry gloves and tape at all times? New gloves to be purchased? Discussion about taking more time to plan and complete the task? THINK OUTSIDE THE BOX!
Is Workers Compensation Required? *
Please ensure that the incident was WORK BASED!
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