Incident Investigation

Incident INvestigation

Supervisor's Name


Was the employee engaged in the regular course of employment when the incident or saefty condition occurred?

Was the employee directed to a doctor?

Was the employee directed to a hospital?

Injury to:


Injury type:

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

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?

Date of last incident: 

Supervisor's Signature: 


Safety Representative's Signature: