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INTEGRITY LMS
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What is the Integrity LMS?
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HBI - Incident Investigation Report
INCIDENT INVESTIGATION REPORT
To be completed and signed by the injured worker, reviewed and signed by the supervisor,
and sent to the Safety Department. Use this form for near-miss incidents also.
Must be submitted within 24 hours
Incident Information
Employee Name
(Required)
First
Last
Job Name
(Required)
Supervisor
(Required)
Place of Incident
(Required)
Date of Incident
(Required)
MM slash DD slash YYYY
Time of Incident
(Required)
Hours
:
Minutes
AM
PM
AM/PM
Type of Incident
(Required)
Near Miss
Injury
Illness
Damage - Property Material Equip.
Nature of Injury
Injured Part of Body
(Required)
Diagnosis of Injury
(Required)
Treatment
(Required)
No Treatment
First Aid
Urgent Care Clinic
ER / Hospital
Other
Results of Injury
Released to Full Duty
Light/Modified Duty
NOT released to any work
Lost Time
Incident Description
Describe what happened (Who, What, Where, Why & How) Be specific and detailed
Contributing Factors (Check all that apply)
Unsafe Acts
Improper PPE or PPE not used
Safety rule violation
By-passing safety devices
Guards not used
Operating without authority
Improper lifting
Improper loading or placement
Failure to warn or secure
Horseplay
Improper work technique
Fatigue/lack of focus
Unsafe Conditions
Congested work area
Inadequate ventilation
Improper material storage
Improper tool or equipment
Insufficient knowledge of job
Poor housekeeping
Poor work area design or layout
Inadequate fall protection
Inadequate lighting
Inadequate guarding of hazards
Slippery conditions
Management Deficiencies
Lack of written procedures/policies
Safety rules not enforced
Hazards not identified
PPE unavailable
Insufficient employee training
Insufficient supervisor training
Inadequate job planning
Poor access, housekeeping
Select All
Incident Analysis – Explain the cause(s) of the incident detail
Was corrective action taken?
Yes
No
If YES, what was the action? If NO, why not?
How bad could the accident have been?
Very Serious
Serious
Minor
What is the chance the accident could happen again?
Very Likely
Likely
Not Likely
Preventative and/or Corrective Actions
Indicated Corrective Actions
Deadline
By Whom
Complete
Indicated Corrective Actions
Deadline
By Whom
Complete
Indicated Corrective Actions
Deadline
By Whom
Complete
Indicated Corrective Actions
Deadline
By Whom
Complete
Investigative Team
Name
Signature
Position/Title
Date
Name
Signature
Position/Title
Date
Name
Signature
Position/Title
Date
Name
Signature
Position/Title
Date
Additional Email 1
Send a notification to an additional email
Additional Email 2
Send a notification to an additional email
