Incident Investigation Report Form

1Incident classification & OSHA recordability

Incident type

🤕 Injury 🤒 Occupational illness ⚠️ Near miss 🏭 Property damage 🌊 Environmental release ⛔ Dangerous occurrence

Injured person's name

Job title

Employment type

Body part affected

Nature of injury / illness

First treatment provided

OSHA Recordability Checker — 29 CFR 1904.7

Check ALL that apply to this case:

Medical treatment beyond first aid (prescription, sutures, surgery, physical therapy)

Days away from work (at least one day beyond day of incident)

Restricted work or job transfer

Loss of consciousness (any duration)

Diagnosis of a significant injury or illness by a healthcare professional

Needle stick / sharps injury involving contamination

Work-related fatality

None of the above apply (first aid only / near miss)

→ Select all applicable criteria above to determine OSHA recordability

Days away from work

Days on restricted work / transfer

OSHA 300 Log — Column

2Incident description & scene preservation

Detailed description of what happened (What was the person doing? What happened? What was the result?)

Exact location within facility

Task being performed at time of incident

Equipment / materials involved

Environmental conditions

Witnesses (names, contact)

3Immediate causes — unsafe acts & unsafe conditions

Immediate causes are the direct substandard acts or conditions that directly caused the incident. These are not root causes — they are symptoms of deeper system failures.

Unsafe act(s) — substandard human behaviour

Unsafe condition(s) — substandard physical state

Barriers / controls that FAILED or were ABSENT

4Root cause analysis — 5-Why method

Start with the immediate cause and ask "Why?" until you reach a management system or organisational failure. "Human error" or "worker inattention" alone is never an acceptable root cause — ask why the system allowed the error to have this consequence. Ref: ISO 45001:2018 §10.2(e)

Problem:
Why 1
	↓
Why 2
	↓
Why 3
	↓
Why 4
	↓
Why 5

Root cause statement (summarise the fundamental cause(s))

5Corrective actions — hierarchy of controls applied

For each root cause identified, assign corrective actions using the Hierarchy of Controls. Start with the highest possible level. "Retrain the worker" alone is insufficient if a higher control is feasible. Ref: ISO 45001:2018 §10.2(f) · Hierarchy: 1-Eliminate 2-Substitute 3-Engineering 4-Admin 5-PPE

Corrective action	Control level	Responsible person	Due date	Status	Verified

6Similar hazards — prevent recurrence elsewhere

ISO 45001 §10.2(d) requires determining whether similar incidents have occurred, or whether similar hazards exist elsewhere. Ref: ISO 45001:2018 §10.2(d)

Could this incident occur elsewhere? Describe locations / operations

Communication and learning plan

7Investigation close-out & authorisation

Investigation status

Open — investigation in progress Pending — awaiting corrective action completion Closed — all CAs verified effective

Close-out notes / effectiveness verification

Lead investigator

Signature

Date completed

EHS Manager / Director

Signature

Date reviewed