Incident Investigation
Incident Details
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Incident Type:
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Slip/Trip/Fall
Struck By
Caught In/Between
Chemical Exposure
Equipment Incident
Vehicle Incident
Severity:
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Near Miss
First Aid
Medical Treatment
Lost Time
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Date & Time:
Location:
Description:
Root Cause:
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Equipment Failure
Human Error
Procedure Not Followed
Inadequate Training
Lack of Maintenance
Contributing Factors (select multiple):
Time Pressure
Distraction
Environmental Conditions
Communication Breakdown
Lack of Supervision
Corrective Actions:
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