Incident Investigation Report

Incident Investigation Report

  • Instructions:
    Complete this form as soon as possible after an incident that results in serious injury or illness. (Optional: Use to investigate a minor injury or near miss that could have resulted in a serious injury or illness.)

  • Date Format: MM slash DD slash YYYY
  • Step 1: Injured employee (complete this part for each injured employee)

  • Step 2: Describe the incident

  • :
  • Number of attachments

  • Step 3: Why did the incident happen?

  • Step 4: How can future incidents be prevented?

  • Step 5: Who completed and reviewed this form? (Please Print)