__________________COUNTY INCIDENT INVESTIGATION REPORT

INSTRUCTIONS: This Incident Investigation Report is a tool for department supervisors and incident

investigation teams to find main causes of illnesses, injuries, and “near misses,” and to take corrective actions.

Departments are strongly encouraged to use this form as a method of reducing hazards in their areas.

Employee Statement Concerning Incident:

Employee Signature: ________________________________

Department: _______________________________________ Date: _____________

Witness Statement:

Witness Signature: __________________________________

Department: _______________________________________ Date: _______________

Equipment Involved: (if applicable)

Name of equipment____________________________________________________________

Manufacturer

Age of equipment

Model and Serial #

Location

Was there equipment failure? Yes No If so explain___________________ ____________________________________________________________________________

Attach equipment history, including maintenance schedules and engineering changes.

Other Factors Involved in the Incident (Walking Surfaces, Work Practices, Work Area Design,

Weather, Previous Incidents, etc,):

Corrective Action to Be Taken: (Use separate paper for additional Information)

Item#

Description

Person Accountable

Target Date

Date Completed

Examples of Corrective Actions:

Improve lighting Improve inspection procedure Use less-hazardous materials Repair or replace equipment or tools

Improve housekeeping Improve ventilation Install safety/guard device Correct building hazards

Investigation Reported Completed by: _______________________________________________________

Title: _____________________________ Date: _________________

Report reviewed by: ____________________________________________________________

Title: ________________________________ Date: ________________

TIPS FOR INCIDENT INVESTIGATION:

1) Find the underlying causes of an injury, illness or “near miss” and to take

corrective actions

2) Point out that incident investigations are NOT intended to assign blame

3) Conduct the investigation immediately after the incident. The scene may change

and our memories may fade soon after the incident.

4) Ask the employee involved in the incident, and the witnesses to the incident to

tell you in their own words exactly what happened. (In separate interview)

5) Repeat the employees’ and witnesses’ descriptions of the event to allow them to

make corrections or additions.

6) Review the competed form with the employees involved to make certain that the

report is accurate.