Incident Investigation Report

1. Incident Details

Date of Incident: [DD/MM/YYYY] Time of Incident: [HH:MM AM/PM] Date Reported: [DD/MM/YYYY] Time Reported: [HH:MM AM/PM] Location: [Specific site address or area, e.g., Warehouse B, Loading Dock] Weather Conditions: [e.g., Sunny, Raining, Windy]

2. People Involved

Injured Person(s):

• Name: [Full Name]
• Job Title: [Role]
• Injury/Illness Description: [Details of injury or illness]
• Part of Body Affected: [e.g., Lower back, Right hand]
• Treatment Provided: [e.g., First aid, Hospital, Ambulance]

Witnesses:

• [Full Name 1], [Role]
• [Full Name 2], [Role]

Investigator Details:

• Name: [Full Name]
• Position: [Role]
• Date of Investigation: [DD/MM/YYYY]

3. Description of Incident

Immediate Cause: [Brief description of what happened immediately before the incident, e.g., Worker slipped on oil spill]

Sequence of Events: [Describe the events leading up to, during and after the incident. Be factual and chronological.]

4. Investigation Findings

Environmental Factors: [e.g., Poor lighting, noise levels, temperature] Equipment Involved: [List tools or machinery, including serial numbers if known] Procedures in Place: [Was there a Safe Work Method Statement (SWMS) or Standard Operating Procedure (SOP)? Was it followed?] Training: [Was the worker trained for this task? When?] PPE Worn: [List what Personal Protective Equipment was being used]

5. Root Cause Analysis

Why did it happen? [Identify the direct cause, e.g., Floor was slippery] Why was the floor slippery? [Identify the contributing cause, e.g., Machine was leaking oil] Why was the machine leaking? [Identify the system failure, e.g., Maintenance schedule was not followed]

6. Immediate Actions Taken

1. [Action 1, e.g., Administered first aid]
2. [Action 2, e.g., Isolated the machine]
3. [Action 3, e.g., Cleaned the spill]

7. Corrective Actions to Prevent Recurrence

Action Required	By Whom	Target Date	Status
[e.g., Repair hydraulic leak]	[Name]	[DD/MM/YYYY]	[Pending/Complete]
[e.g., Review maintenance logs]	[Name]	[DD/MM/YYYY]	[Pending/Complete]
[e.g., Re-train staff on spill reporting]	[Name]	[DD/MM/YYYY]	[Pending/Complete]

8. Sign-off

Investigator Signature: __________________________ Date: __________

Manager/PCBU Signature: __________________________ Date: __________