HEALTH AND SAFETY INCIDENT INVESTIGATION FORM

Use this template to record your investigation findings and outline your recommendations. The extent of
detail will be dependent on the severity of the incident. On completion save this template and forward via
e-mail to Quality Section.

Name of Investigation Team Leader (Health & Safety Advisor)

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Name and Title of Supervisor

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Name and Title of the Injured
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Name and Title of Witness to Incident / identifier of hazards/near miss

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Name and Title of Security Representative

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Incident Date

31-May-15

Summary of Investigation Findings

The summary should outline the event, who was involved, what happened, the scope of the investigation,
the analysis and outcomes and any recommendations to prevent or minimize the recurrence of the
incident

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 Witnesses

Please include section / contact details of witnesses

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Investigative Analysis
Immediate cause Root cause Corrective action Corrective action
assign to whom and
what time frame?
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text.
 Recommendations

Outline recommended corrective action/s (i.e. solution/s) to prevent the recurrence of the
incident.(Number the recommendations from most effective to least effective, i.e. Hierarchy of Controls)

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Please sign off this form as evidence of implementation of corrective action

Head of Sections Name: Click here to enter text.

Health and Safety Advisors name: Click here to enter text.

I, Click here to enter text. certify that the agreed corrective action

has been implemented

Health and Safety Section:

Signature/Date:

Head of Department:

Signature/Date: