HBI - 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)
MM slash DD slash YYYY
Time of Incident(Required)
Type of Incident(Required)

Nature of Injury


Results of Injury

Incident Description

Contributing Factors (Check all that apply)

Unsafe Acts
Unsafe Conditions
Management Deficiencies

Incident Analysis – Explain the cause(s) of the incident detail

Was corrective action taken?
How bad could the accident have been?
What is the chance the accident could happen again?

Preventative and/or Corrective Actions

Investigative Team

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