Incident Investigation Form
Employee Injury or Illness
Name:
Occupation:
Part of body:
Nature of injury or illness:
Object/equipment/element inflicting injury or illness:
Person with most control of object/equipment/etc.:
Act or activity at time of accident:
Exact location:
Fleet or Property Damage
Property Damaged:
Estimated cost:
Actual cost:
Nature of damage:
Vehicle speed:
Object/equipment inflicting damage:
Registration #:
Person with most control - inflicting damage:
Department:
Date of occur:
Time (am/pm):
Date reported:
Description of Occurrence:
Type of Incident
Type of Incident:
Aid of Person
Fall
Collision/Implosion
Cut/Pierce
Muscular Effort - Single
Manual Handling Injury
Muscular Effort - Repetitive/Continuous
Muscular Effort - Postural
Non-person Related Incident
Struck by Object
Extreme Temperature
Electrical Current
Harmful Substances
Radiation
Exposure to Noise
Type of Injury
Type of Injury:
No injury reported
Fractures/Dislocation
Sprains/Strains
Concussion
Lacerations/Open cuts
Damage to glasses, hearing aids etc
Burns and Scalds
Puncture/Penetration
Occupational
Overuse/Injuries
Poisoning and Toxic Effects
Confusions/Bruising/Crushing
Grazes/Abrasions
Foreign Bodies
Wounds
Amputations
Electric Shock
Multiple Injuries
Bites/Stings
Apparent Type of Illness
Apparent Type of Illness:
Epilepsy
Dermatitis/Skin Rashes
Dizziness/Fainting
Nausea/Vomiting
Circulatory System/Heart Problem
Respiratory System/Breathing Problems
Infectious and Parasitic Diseases
Psychological Disorders (e.g. Stress)
Deafness
Headaches
Shock
Bodily Location
Bodily Location:
Face
Head
Neck
Shoulder
Arm
Hand and Fingers
Trunk
Back
Hip
Leg
Feet and Toes
Internal Organs
Multiple Parts
General/Unspecified Location
Psychological
Agency (What caused the incident?)
Agency:
Animal(s)
Chemical(s)
Physical Environment
Insects
Floors and Passageways
Stairs
Fixed or Mobile Plant/Machinery
Ground and Pathways
Hand Tools (Non-powered)
Road Transport (Cars, Bikes, etc.)
Equipment (Includes Powered Tools)
Syringes
Biological Agencies
Manual Handling
Person/People
Slips/Trips/Falls
Inadequate Training
Foreign Bodies
Objects
When did the Incident Occur?
When did the Incident Occur?
During Work Time
During Break from Work
Journey to/From Work
Other
Where did the Incident Occur?
After the Incident
Did the person:
Return to Work
Go Home
Go to the Doctor
Go to the Hospital
Other
First Aid Received:
Yes
No
Was there any time lost?
Yes
No
From:
To:
Duration (Days/Hours):
Loss Severity Potential:
Major
Serious
Minor
Probable Recurrence Rate:
Frequent
Occasional
Rare
Actions to be taken
Action 1:
Action 2:
Action 3:
Supervisor of Injured Person:
Reviewed By:
Submit