INCIDENT INVESTIGATION REPORT Investigation Details Occupational Injury Occupational Illness Occupational Near Miss Employee Name: Position: Incident Date: Incident Time: Report Date: Summary of Incident (includes staff members’ description, relevant details, etc.): (Attach witness statements, if necessary) Hazard Assessment Frequency: Severity: Probability: One or more times/day 4 4 Serious injury/death 4 Expect it to happen 100% of the time One or more times/week 3 3 Medical aid 3 Could happen 50% of the time One or more times/month 2 2 Minor injury 2 to have It’s possible, known happened Less than once/month 1 1 No injury/damage 1 Practically impossible Risk Criticality Ranking (3 to 12 from least to most hazardous): Incident Description Describe how the incident occurred (includes investigators complete description answering who, where, why, what, when, and how):
INCIDENT INVESTIGATION REPORT Investigation Details Occupational Injury Occupational Illness Occupational Near Miss Employee Name: Position: Incident Date: Incident Time: Report Date: Summary of Incident (includes staff members’ description, relevant details, etc.): (Attach witness statements, if necessary) Hazard Assessment Frequency: Severity: Probability: 4 One or more times/day 4 Serious injury/death 4 Expect it to happen 100% of the time 3 One or more times/week 3 Medical aid 3 Could happen 50% of the time 2 One or more times/month 2 Minor injury 2 It’s possible, known to have happened 1 Less than once/month 1 No injury/damage 1 Practically impossible Risk Criticality Ranking (3 to 12 from least to most hazardous): Incident Description Describe how the incident occurred (includes investigators complete description answering who, where, why, what, when, and how):
2015_incident_investigation_report.docx