ISS Incident Investigation 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 hoursIncident InformationEmployee 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 InjuryInjured 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 DescriptionDescribe what happened (Who, What, Where, Why & How) Be specific and detailedPhotos of the area/incident (4 or more) Drop files here or Select files Max. file size: 20 MB, Max. files: 14. 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 Other 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 Other 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 Other Explain Unsafe ActExplain Unsafe ConditionExplain Management DeficienciesIncident Analysis – Explain the cause(s) of the incident detailWas 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 ActionsIndicated Corrective ActionsDeadlineBy WhomCompleteIndicated Corrective ActionsDeadlineBy WhomCompleteIndicated Corrective ActionsDeadlineBy WhomCompleteIndicated Corrective ActionsDeadlineBy WhomCompleteInvestigative TeamNameSignaturePosition/TitleDateNameSignaturePosition/TitleDateNameSignaturePosition/TitleDateNameSignaturePosition/TitleDate
