Incident Investigation | Tree-Ripe Fruit Co.

1

Reference

Employee involved

Date of incident

Completed by

Your role

Date completed

Relationship to employee

2

What was the employee doing at the time of the accident?

Was the employee qualified to perform this operation?

Yes No Unsure

Were company procedures being followed?

Yes No Unknown

If procedures were not followed, what happened?

3

Is the job or process new?

Yes No

Were proper tools or equipment being used?

Yes No N/A

Was the proper supervision being provided?

Yes No

Had the employee received training on this operation before the accident?

Yes No Unknown

Where did the accident take place?

What was the physical condition of the area when it happened?

What were witnesses doing at the time?

4

What immediate action could have prevented it or reduced its effect?

What long-term action could prevent this in the future?

Had corrective action been recommended in the past but not adopted?

Yes No Unknown

If yes, what was recommended and why wasn't it put in place?

5

Investigator or witness signature

Your typed name counts as your signature.

Date

Supervisor signature

Your typed name counts as your signature.

Date