Incident Investigation Checklist

Walk through the questions an investigator needs to answer after a workplace event: procedures, training, protective gear, equipment and supervision. Each answer builds a picture of what went wrong and who must act next. The review closes with a corrective task list, a date and a signature.

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Are there any written procedures for the task to be accomplished?

Yes No Partially Not applicable

Was the employee provided with training or informed about the procedure?

Yes No Partially Not known

Is the employee physically and mentally capable of carrying out the tasks?

Yes No Not known

Was the employee provided with the personal protective equipment (PPE) and was he/she correctly wearing them?

Provided and worn correctly Provided but not worn Not provided Not required for the task

Was enough time provided for the employee to accomplish their tasks?

Yes No Not known

Was there any equipment involved in the incident?

Hand tools Power tools Fixed machinery Vehicle or forklift Ladder or scaffold No equipment involved

How did the equipment contribute to the incident?

Mechanical or electrical failure Missing guard or shield Poor maintenance Wrong tool for the job Improper use by the operator Not a contributing factor

Which of the following environmental factors has contributed to the incident?

Poor lighting Excessive noise Extreme temperature Slippery or uneven floor Poor housekeeping Weather conditions None of these

Is the role of management clearly defined and assigned in hazard recognition and corrective action?

Yes No Partially

Is management trained in hazard recognition?

Yes No Not known

Was management aware of a potential deviation that might occur from safety procedures?

Yes No Not known

Please explain the main cause of the incident and what measures could have been taken to prevent it?

Date

Signature

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