Incident Investigation

Incident INvestigation

Supervisor's Name

Title

Was the employee engaged in the regular course of employment when the incident or saefty condition occurred?
 Yes
 No

Was the employee directed to a doctor?
 Yes
 No

Was the employee directed to a hospital?
 Yes
 No

Injury to:

HeadArmFaceGlasses/Contact
 HandLegEyeOther: 
FootBackTeeth 

Injury type:

 Wound Bruise Spriain/Strain Disease/Infection
 Hernia Burn Fracture Previous injury aggravated
   Other: 

Contributing casue(s), if any?

 Operating without Authority Operating at unsafe speed
 Taking unsafe position Making saefty devices inoperative
 Distraction, horseplay Using unsafe loading/mixing procedures
 Failure to use protective devicesWorking on moving/dangerous equipment
 Using unsafe equipment Using equipment unsafely

Descrition of incident or safety condition:

What could have been done to prevent this type of incident?

Has the employee  been consuled on a similar behavior related to this incident?
 Yes
 No

Date of last incident: 

Supervisor's Signature: 

Date:

Safety Representative's Signature: 

Date: