Incident Report - Full Investigation & Report Checklist
Facility Management
Incident Management
Safety
Data Collection
Collect evidence, find root causes and investigate incidents, accidents and injuries. Create a comprehensive incident investigation report. Go deeper than an early incident report template.
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Audit

Incident Details

Date & Time of Incident
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Address

Location of Incident
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Incident Severity?
Urgent
High
Medium
Low
Trivial
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Site / Project Name
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Incident Type (select all that apply)
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Please describe type of incident
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Name of on-duty supervisor at time of incident?
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Was medical attention administered?
Yes
No
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What kind of medical attention was administered?
Search and select all that apply
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Please detail medical attention
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Incident Summary

Describe what happened. Please be detailed but state only facts.
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Do you wish to include a timeline of events for this incident?
Yes
No
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Incident Timeline

Event Date / Time
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Event Description
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What were the weather / environmental conditions at the time of the incident?
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Describe the weather / environmental conditions at the time of the incident
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Evidence and Attachments

Which of the following do you need to attach to this report to accuractly document this incident?
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Evidence Log

Evidence Description
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Evidence ID number (if applicable)
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Type of evidence
Document
Photos
Other
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Photos of evidence (if applicable)
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Please detail any further information regarding this evidence (if applicable)
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Vehicle Log

Vehicle Make
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Vehicle Model
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Vehicle Registration
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Driver (if applicable)
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Photos of equipment (if applicable)
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Please detail any further information regarding this vehicle (if applicable)
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Damage Log

Damage description
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ID number (if applicable)
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Photos of damage (if applicable)
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Please detail any further information regarding this damage (if applicable)
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Other Items Log

Item description
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ID number (if applicable)
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Photos of item (if applicable)
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Please detail any further information regarding this item (if applicable)
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Equipment Log

Equipment Make
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Equipment Model
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Equipment ID number (if applicable)
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Photos of equipment (if applicable)
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Please detail any further information regarding this equipment (if applicable)
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People involved

Person

Full Name
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ID number
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Contact phone number
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What is this person's relation to the incident? (select all that apply)
Search and select all that apply
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Describe this person's relation to the incident
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Please describe this person's involvement with the incident, including all relevant information
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Attach any relevant photos regarding this person
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Do you want to log a statement for this person?
Yes
No
N/A
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Statement

Statement regarding incident
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Signature

Person Signature
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Date & Time of Statement
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Has this person sustained an injury?
Yes
No
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Injury Details

Type of injury or illness? (select all that apply)
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Describe type of injury or illness
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Parts of body affected? (select all that apply)
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Please describe injury location
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Describe this injury or illness
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What was the cause of this injury or illness?
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Corrective Actions

Are corrective/further actions required with regard to this incident?
Yes
No
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Have all required corrective actions been added as Actions to this inspection?
Yes
No
N/A
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Root Cause Analysis / Contributing Factors

What were the contributing factors to this incident occurring? (select all that apply)
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Has the root cause of this issue been able to be identified?
Yes
No
N/A
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Why is the root cause for this issue unable to be identified at this time?
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How likely is this incident to reoccur in future?
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What is the root cause of this incident? Please consider and include all contributing factors
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Has the root cause of this issue been rectified or eliminated?
Yes
No
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How was the root cause rectified or eliminated?
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Please attach any relevant photos or media
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Please provide any relevant further details
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How likely is this incident to reoccur in future?
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Sign Off

Further action/follow-up/investigation required?
Yes
No
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Name of person/people to follow up
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Signature

Name & Signature of Investigator
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