Quality, safety & admin
Incident investigation report template
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Preview — Organised table
Incident Investigation Report
Date: Date
Incident
| Item | Details |
| --- | --- |
| Date and Time | Date and Time |
| Location | Location |
| Incident Type | Incident Type |
| Injured | Injured |
| Damage | Damage |
Description
| Item | Details |
| --- | --- |
| What Happened | What Happened |
| Witnesses | Witnesses |
Cause analysis
| Item | Details |
| --- | --- |
| Immediate Cause | Immediate Cause |
| Root Causes | Root Causes |
| Contributing Factors | Contributing Factors |
Actions
| No. | Action | Owner | Due | Status |
| --- | --- | --- | --- | --- |
| 1 | Action 1 | Owner 1 | Due 1 | Status 1 |
| 2 | Action 2 | Owner 2 | Due 2 | Status 2 |
| 3 | Action 3 | Owner 3 | Due 3 | Status 3 |
| 4 | Action 4 | Owner 4 | Due 4 | Status 4 |
| 5 | Action 5 | Owner 5 | Due 5 | Status 5 |
Investigator: Investigator
Signature: Signature
Safety Manager: Safety Manager