Management Incident Investigation Report

Incident:

Injury – First Aid Only
Injury – Medical Treatment
Property Damage
Near Miss – Record Only

Injured Employee *

First

Last

Job Title *

Supervisor *

First

Last

Date and time of incident *

Date

Time

Date incident reported *

City, state, zip code where incident occurred *

Witnesses *

SUMMARY – describe the incident. *

ANALYSIS – Describe conditions that led to the incident (environmental conditions, tools/equipment used or task being performed). Identify possible causes for the accident and if/how it could be avoided. *

RECOMMENDATIONS – Describe any controls and/or corrective procedures that may prevent the recurrence of similar incidents. *

ACTION TAKEN – Describe measures taken by management to improve the system (employee training, new equipment, changes in safety policies, changes in operating procedures, etc.) and to prevent occurrence of similar incidents. Include who the action(s) is/are assigned to and date implemented. *

Report completed by *

Date *