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    7 (MPH) Incident Investigation Report Form

    Uploaded by

    Lwandziso Dlamini
    This incident investigation report form contains sections to document details of a workplace accident such as the employee involved, date and time of accident, witnesses, accident description, findings, corrective actions, and signatures. The form is used to investigate the sequence of events, root cause, contributing factors, injuries, and hazardous conditions identified so that recommendations can be made to prevent future accidents.

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    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd

    7 (MPH) Incident Investigation Report Form

    Uploaded by

    Lwandziso Dlamini
    11 views3 pages
    This incident investigation report form contains sections to document details of a workplace accident such as the employee involved, date and time of accident, witnesses, accident description, findings, corrective actions, and signatures. The form is used to investigate the sequence of events, root cause, contributing factors, injuries, and hazardous conditions identified so that recommendations can be made to prevent future accidents.

    Original Title

    7 (MPH) INCIDENT INVESTIGATION REPORT FORM

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    This incident investigation report form contains sections to document details of a workplace accident such as the employee involved, date and time of accident, witnesses, accident description, findings, corrective actions, and signatures. The form is used to investigate the sequence of events, root cause, contributing factors, injuries, and hazardous conditions identified so that recommendations can be made to prevent future accidents.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    11 views3 pages

    7 (MPH) Incident Investigation Report Form

    Uploaded by

    Lwandziso Dlamini
    This incident investigation report form contains sections to document details of a workplace accident such as the employee involved, date and time of accident, witnesses, accident description, findings, corrective actions, and signatures. The form is used to investigate the sequence of events, root cause, contributing factors, injuries, and hazardous conditions identified so that recommendations can be made to prevent future accidents.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 3

    Doc No: MPH/SHERQ/007/2021

    Rev No: 02
    Date: April 2021
    Page: 01 of 02
    INCIDENT INVESTIGATION REPORT FORM Status: Approved

    Employee name Employee job title Gender Cell phone number

    Work location
    Date of accident Time of accident
    Classification (new worker, trainee, experienced)
    Investigator Cell number :
    Investigation team Contact details Positions
    1.
    2.
    3.
    4.
    Witnesses Contact details Signatures
    1)
    2)
    3)
    4)

    ACCIDENT DESCRIPTION
    What happened

    Root cause

    Contributing factors

    Sequence of events that led to injury


    Description of the surroundings

    What was happening at the time of accident and why

    Describe the injury

    ACCIDENT FINDINGS
    Casual factors (procedure, equipment, people ,environment)

    Hazardous condition

    Unsafe work practice

    Corrective action Person responsible Target Date

    Actions taken to ensure recommendations are considered

    Signatures
    Signature of Supervisor Date:
    Safety officer Date:
    Person injured Date:

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