INCIDENT INVESTIGATION THE MINIMUM QUESTIONS TO THE SOLUTION INCIDENT INVESTIGATION: Checklist of information and Analysis Description of Injured: Employee Number: Last Name: First Name: Initial: Age: __ Length of service: Length of service on present job: Safety training received: Date safety training received: Supervisor in charge at time of accident: Names of any witnesses: Information: Description of Accident Location: Date Time: Accident type: Machinery/Equipment involved: Date of last service/inspection: Were people involved? What type of Environment: Was ventilation adequate? State of working surfaces: Were chemicals involved in accident? Details: Any other factors involved in accident: The Injury: Nature? Was First Aid administered? Was hospital treatment required? Length of time away from work: Days Was the injured wearing specified PPE at time of accident? Was task authorized? Specify any legal regulations which related to any of the circumstances surrounding the accident: Have any similar accidents occurred before in the above location? DATE DESCRIPTION Has a member of the health and safety committee investigated this accident? (if yes, attach his/her findings): Findings: Analysis of Causes: 1. Name persons interviewed as part of this investigation: State briefly their observations as to causes: NAME OBSERVATIONS 2. From all the information contained in Part 1 and from observations obtained from interviews, inspections of workplace, equipment involved, list all possible and probable causes. (Note: Direct, contributing and underlying causes to be included, e.g., if machine guard missing, state why this happened) List these causes as they may relate to all or any of the following: Organization (including company policy, procedures, training, supervision, maintenance, purchasing, controls, etc.): Machinery/Equipment: Working practices: Environmental factors: - Recommendations: List recommendations for changes in any of above necessary to prevent a recurrence of this accident or other accidents which may result from defects noted above.