Sample Incident Investigation Forms

Sample #1 Incident Investigation Form
The reason for investigating an incident or near miss is to determine: the cause or causes of the incident;
to identify any risks, hazards, systems or procedures that contributed to the incident; and to recommend
corrective action to prevent similar incidents.
Incidents should be investigated by people knowledgeable about the type of work involved at the time of
the incident. The JOHSC or relevant workers should also be involved in the investigation.
An incident /near miss investigation report should answer the WHO, WHERE, WHEN, WHAT, WHY
and HOW questions with regard to an incident.
Note: this template is for internal use only.
(INSERT YOUR BUSINESS NAME HERE)
Details of the incident/near miss:

Short description of incident / near miss:
Area where incident / near miss occurred:

Date of incident: Time of incident:
Details of the incident/near miss investigation

Name of injured person (if relevant): Injury sustained
Name of person who reported incident: Date of report:
Name of person completing this form:
Telephone number: Date report completed:
Witness details
Name/s Job title (if relevant) Contact number
Name of investigator Job title (if relevant) Contact number

Full description of events
(Briefly describe what happened including the sequence of events, investigate scene of incident or near
miss; who was involved e.g. worker, visitor; conditions present at time of incident; what was involved,
what activity (if any) was taking place prior and at time of incident. What hazards was the worker
exposed to? What hazards may have contributed to the incident occurring? Attach photos if available)
Complete the following based on the type of incident (if applicable)

Yes No
NS Department of Labour Contacted
WCB of Nova Scotia Notified
Incident scene preserved (required by law)
Comments:
INVESTIGATION RECOMMENDATIONS eg. new equipment, re-engineer, re-design work

area, re-design work practices, review training standards, etc
IMPLEMENTATION DETAILS including action taken, date implemented, responsible person…..
Supervisor Signature Date

Sample #2 Incident / Accident
Report & Investigation Form
1. Person(s) Involved:
Name:
Contact No: Department / Section:
Employee: Student: Contractor: Other (Specify):
2. Details of near miss / incident / accident:
Location:
Date: Time: am / pm
3. Severity:
Fatal Serious Harm Minor Harm No Harm / Near Miss
4. Treatment:
Nil First Aid CPR Doctor Hospital
What treatment was given?
By Whom
5. Description of what happened:
6. Describe the cause of incident / accident: ______________
Contributory Factors (refer to these when identifying the cause of the near miss / incident / accident)
Immediate Causes Substandard Acts
- Guarding - Operating without authority
- Defective tools or equipment - Disabling safety devices
- Hazardous arrangements - Using unsafe equipment
- Unsafe conditions - Non use of Personal Protective Equipment
- Unsafe design - Non use of lock out / isolation systems
- Housekeeping - Unsafe positioning
- Environmental conditions - Distraction / fooling about
7. Has a significant hazard been identified? Y/N
If yes, please investigate this hazard and update the Hazard Register in
your department or section accordingly
8. Chance of the near miss, incident or accident recurring:
One off Daily Weekly Monthly 6 Monthly +
9. Corrective Action: (What will be done to minimise the risk of this happening again)
Action By Whom Completed
Person in control of the workplace: Name:
Signed: Position:
10. Supervisor’s Comments:
Signed: Position:
Date:
11. Health and Safety Co-ordinator’s comments:
Date:
12. Incident / Accident recorded on Accident Register and all corrective actions completed:
Signed: Date:
Sample #3 Incident Investigation Form
Company Name
Date:
Who was involved?
What happened?
When? Date:
Time:
Where?
What were the immediate causes?
What were the underlying causes?
What training, instruction, cautions were given before the incident?
How can similar incident be prevented in the future?
Person in Charge:
Signature:
Reviewed by Senior Manager:

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Sample Incident Investigation Forms

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Sample #1 Incident Investigation Form

Note: this template is for internal use only.

(INSERT YOUR BUSINESS NAME HERE)

Details of the incident/near miss:

Area where incident / near miss occurred:

Details of the incident/near miss investigation

Name/s Job title (if relevant) Contact number

Name of investigator Job title (if relevant) Contact number

Complete the following based on the type of incident (if applicable)

WCB of Nova Scotia Notified

Incident scene preserved (required by law)

INVESTIGATION RECOMMENDATIONS eg. new equipment, re-engineer, re-design work

IMPLEMENTATION DETAILS including action taken, date implemented, responsible person…..

Supervisor Signature Date

Contact No: Department / Section:

Employee: Student: Contractor: Other (Specify):

2. Details of near miss / incident / accident:

Fatal Serious Harm Minor Harm No Harm / Near Miss

Nil First Aid CPR Doctor Hospital

What treatment was given?

5. Description of what happened:

6. Describe the cause of incident / accident: ______________

8. Chance of the near miss, incident or accident recurring:

One off Daily Weekly Monthly 6 Monthly +

Person in control of the workplace: Name:

10. Supervisor’s Comments:

11. Health and Safety Co-ordinator’s comments:

What were the underlying causes?

What training, instruction, cautions were given before the incident?

How can similar incident be prevented in the future?

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