Incident Investigation – My Workplace Hub

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Incident Report #(Required)

This number can be found on the Incident Report PDF.

Date of the Incident(Required)

Investigators Email:(Required)

Incident Type(Required)

Department(Required)

Specific Location of Incident(Required)

Time on Job(Required)

Length of time on the same job at the time of incident.

Specific Body Part's Injured(Required)

What object or substance directly harmed the employee?(Required)

Description of Incident / Injury / Damage Etc.(Required)

Injury, Property Damage, Environmental, or Other

Incident Photos / Witness Statements / Other Documents

Max. file size: 512 MB.

Describe First Aid or Emergency Response

Root Cause Analysis Findings:(Required)

5 Whys: Ask “Why?” five times to drill down to the root cause. Example of 5 Whys: Why did the machine stop? → The motor overheated. Why did it overheat? → The cooling fan wasn’t working. Why wasn’t it working? → The fan belt was broken. Why was the belt broken? → It was worn out and not replaced. Why wasn’t it replaced? → No preventive maintenance schedule was in place. → Root Cause: Lack of a preventive maintenance program.

Corrective actions:(Required)

Assigned responsibilities and deadlines:(Required)