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152 Supervisors’ Safety Manual
Incident Investigation Report
Case Number _____________________
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_________________________________________________ ____________________________________________________________________
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_________________________________________________ ____________________________________________________________________
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_________________________________________________ ________________________________ ____ / ____ / ____
9. Employment category
Regular, full-time Regular, part-time Temporary
Seasonal Non-Employee
10. Length of employment
Less than 1 mo. 1-5 mos.
6 mos. - 5 yrs. More than 5 yrs.
11. Time in occup. at time of the accident
Less than 1 mo. 1-5 mos.
6 mos. - 5 yrs. More than 5 yrs.
12. Nature of injury and part of the body
_________________________________________________
13. Case numbers and names of others injured in same accident
____________________________________________________________________
14. Name and address of physician
_________________________________________________
15. Name and address of hospital
_________________________________________________
_________________________________________________
_________________________________________________
16. Time of injury
A. a.m.
p.m.
B. Time within shift _________________
C. Type of shift ____________________
17. Severity of injury
Fatality
Lost workdays - days away from work
Lost workdays - days of restricted activity
Medical treatment
First Aid
Other, specify ____________________
18. Specific location of incident
_________________________________________________
_________________________________________________
On employer’s premises?
Yes No
19. Phase of employee’s workday at time of injury
During rest period Entering or leaving plant
During meal period Performing work duties
Working overtime Other
20. Describe how the incident occurred
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
21. Incident sequence. Describe in reverse order the occurence of events preceding the injury and accident.
Start with the injury and moving backward in time, reconstruct the sequence of events that led to the injury.
A. Injury event _____________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
B. Incident event ___________________________________________________________________________________________________________
________________________________________________________________________________________________________________________
C. Preceding event #1 _______________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
D. Preceding event #2, 3, etc. _________________________________________________________________________________________________
________________________________________________________________________________________________________________________
6. Home Address
_________________________________________________
7. Employee’s usual occupation
________________________________
8. Occupation at the time of the accident
__________________________________
23. Posture of employee
_________________________________
_________________________________
24. Supervision at time of incident
Directly supervised Indirectly supervised
Not supervised Supervision not feasible
22. Task and activity at time of incident
General type of task _____________________________________________________
Specific activity ________________________________________________________
Employee was working:
Alone
With crew or fellow worker
Other (specify)
Figure 7–2. Complete an Incident Investigation Report after you have gathered all possible evidence.
See the text for information on how to complete this form.
©2009 National Safety Council.