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Incident Investigation Form

This document is intended for internal use, serving as a quick means of communication between workers and management to promptly record incidents that may necessitate notification to the Quality & Safeguards Commission. Please fill out and include all necessary information.

Your name

Name of person involved in incident

Location of Incident

Your Contact Number

Date of Incident

Position of person reporting

Time of incident

Have you documented this incident

Describe the incident

Circumstances leading up to the incident

Details of harm or potential harm caused

What factors contributed to the incident? Please tick applicable.

ENVIRONMENT

Noise

Layout/design

Lighting

Slip / Trip Hazard

Damaged or unstable floor

Dust / Fume

Medications

If other, please explain

EQUIPMENT / MATERIALS

Wrong equipment for job

Equipment Failure

Inadequate maintenance

Material / equipment too heavy / awkward

Inadequate training provided

Inadequate guarding

If other, please explain

WORK SYSTEMS

Hazards not identified

No / inadequate risk assessment conducted

No / inadequate safe work procedure

No / inadequate safe work procedure

No / inadequate controls implemented

Hazard not reported

Inadequate training / supervision

If other, please explain

PEOPLE

Procedure notfollowed / no procedure exists

Drugs / Alcohol

Lack of communication

Time / production pressures

Fatigue

Change of routine

Distraction / personal issues / stress

If other, please explain

ACTIONS

Contributing factor (from above list)

What are we going to do to fix the problem?

Who and When

Contributing factor (from above list)

What are we going to do to fix the problem?

Who and When

Contributing factor (from above list)

What are we going to do to fix the problem?

Who and When

If there are any documents supporting the information provided in this incident form, please attach them as part of this form.

Upload Document File Here

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Upload Image File Here

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Thanks for submitting!

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