INSTRUCTIONS FOR INVESTIGATION REPORT
1. COMPANY
2. DEPARTMENT
A
3. LOCATION OF INCIDENT
4. DATE OF INCIDENT
IDENTIFYING INFORMATION
INJURY OR ILLNESS
10. NATURE OF ILLNESS
9. DAYS LOST
B
11. OCCUPATION
16. NATURE OF INCIDENT
14. NATURE OF DAMAGE
17. INCIDENT COST, IF APPLICABLE
ESTIMATED
ACTUAL
18. PERSON REPORTING INCIDENT
19. OBJECT/EQUIPMENT/SUBSTANCE INFLICTING HARM
20. PERSON WITH MOST CONTROL OF ITEM 11
Struck against
Struck by
Caught in
RISK
C
12. TIME ON TASK
21. TYPE OF CONTACT
DESCRIPTION
OTHER INCIDENTS
13. PROPERTY DAMAGE
15. COST
6. DATE OF REPORT
PM
PROPERTY DAMAGE
7. INJURED’S NAME
8. PART OF BODY
AM
5. TIME
EVALUATION OF LOSS
POTENTIAL IF NOT CORRECTED
D
Caught on
Caught between
Slip
Fall on same level
Fall to lower level
Overexertion
22. LOSS SEVERITY POTENTIAL
Severe
Serious
E
Minimal
CONTACT WITH
Electricity
Heat
Cold
Radiation
Caustics
Noise
Toxic or noxious substances
23. PROBABILITY OF REOCCURRENCE
High
Medium
24. DESCRIBE HOW THE EVENT OCCURRED.
F
CAUSE ANALYSIS
25. IMMEDIATE CAUSES, WHAT SUBSTANDARD ACTIONS AND CONDITIONS CAUSED OR COULD
CAUSE THE EVENT? CHECK ON BACK (25A), EXPLAIN HERE.
26. UNDERLYING CAUSES, WHAT SPECIFIC PERSONAL OR JOB FACTORS CAUSED
OR COULD CAUSE THIS EVENT? CHECK ON BACK (26A), EXPLAIN HERE.
G
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INSTRUCTIONS FOR INVESTIGATION REPORT
26A. UNDERLYING CAUSES (Check all that apply.)
25A. IMMEDIATE CAUSES (Check all that apply.)
INCIDENT NEEDS
Substandard Actions
Personal Factors
Substandard Conditions
Operating equipment without authority
Failure to warn
Failure to secure
Operating at improper speed
Making safety devices inoperable
Removing safety devices
Using defective equipment
Using equipment improperly
Failing to use personal protective equipment properly
Improper loading
Improper placement
Improper lifting
Improper position for task
Servicing equipment in operation
Horseplay
Under influence of alcohol and/or other drugs
Operating equipment without authority
Inadequate or improper protective equipment
Defective tools, equipment or materials
Congestion or restricted action
Inadequate warning system
Fire and explosion hazards
Poor housekeeping/disorder
Hazardous environmental conditions:
gases, dusts, smoke, fumes, vapours
Noise exposure
Radiation exposure
High or low temperature exposure
Inadequate or excess illumination
Inadequate ventilation
Inadequate capability
Lack of knowledge
Lack of skill
Stress
Improper motivation
G
Job Factors
Inadequate leadership/supervision
Inadequate engineering
Inadequate purchasing
Inadequate maintenance
Inadequate tools/equipment/materials
Inadequate work standards
Wear and tear
Abuse and misuse
27. MANAGEMENT CONTROL (Check all that apply.)
CONTROLS
Program Elements
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
P
S
C
P
Leadership and administration
Leadership training
Planned inspections and maintenance
Critical task analysis and procedures
Accident/incident investigation
Task observation
Emergency preparedness
Rules and work permits
Accident/incident analysis
Knowledge and skill training
H
Legend: P – Program element implementation need
S
C
Personal protective equipment
Health and hygiene control
System evaluation
Engineering and change management
Personal communications
Group communications
General promotion
Hiring and placement
Materials and services management
Off-the-job safety
S – Standard(s) inadequate
28. REMEDIAL ACTIONS, WHAT HAS AND/OR SHOULD BE DONE TO CONTROL THE CAUSES LISTED?
ACTION PLAN
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
C – Compliance with standard(s) inadequate
DEADLINE
BY WHOM
COMPLETE
I
29. SIGNATURE OF INVESTIGATOR
DATE
30. SIGNATURE OF REVIEWER
DATE
31. REVIEWERS’S REACTIONS TO THE INVESTIGATOR’S ANALYSIS OF THE BASIC CAUSES AND REMEDIAL ACTIONS.
J
SIGNATURE
TITLE
DATE
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110-007-06-IGDO © 2015, Workplace Safety & Prevention Services (WSPS)
1 877 494 WSPS (9777) | 905 614 1400 | www.wsps.ca
INSTRUCTIONS FOR INVESTIGATION REPORT
Section A:
Input the name of the company, department, location, date and time of where and when the injury or
illness occurred.
Questions #4 and 5: Record the date and time of when the injury/illness occurred.
Ŷ
For example: A fall or a cut from a machine; an allergic response to a chemical.
If the injury or illness did not suddenly occur but rather happened over a period of time (i.e. an MSD
or a respiratory disease), you must record an approximate date you first started to notice it.
Question #6: Input the date the investigation report is being filled out.
Section B:
In this section, record the name of the injured, his or her job title, and the duration of time he or she
was working on that task.
For example:
Ŷ
Ŷ
Ŷ
Question #8: Specify the body part.
Question #9: Record the number of days the worker missed due to the injury. This count should
be started on the day which the injury/illness occurred (date inputted in question 4).
Question #10: This indicates the type of injury that occurred, for example a burn or fracture.
Specify how the injury or illness occurred.
Section C:
Identify any property damage by listing the piece of property that was damaged (#13); the nature of
the damage (i.e. fire, explosion – #14); and the cost of the damage. In #15, record the costs involved,
and whether they are estimated or actual.
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110-007-06-IGDO © 2015, Workplace Safety & Prevention Services (WSPS)
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INSTRUCTIONS FOR INVESTIGATION REPORT
Section D:
In this section, check all factors that apply to the injury or illness, in order to help identify how the
injured worker came into contact with the material and/or equipment, or what form of energy caused
the initial contact.
Ŷ
Ŷ
Type of Contact: Check off all types of contact the worker experienced during the incident
(i.e. struck by forklift, fall on same level, fell down when hit).
Contact With: Check off all sources of contact during the incident, if this applies.
Section E:
When assessing a hazard, you are in the process of determining how serious its consequences could
be and therefore setting priorities for action. For example, hazards that threaten death or permanent
disability should be given the highest priority for action. To help you classify hazards according to their
severity, use the following guidelines.
Loss Severity Potential
Severity is the magnitude of potential loss (any type). By using these definitions as a guideline, you can
determine which severity level will be associated with each hazard.
Level
Description
Ŷ
Severe
Ŷ
Ŷ
Ŷ
Serious
Ŷ
Minimal
Ŷ
Ŷ
Death or permanent disability
Loss of body part
Extensive loss of structure, equipment or material
Serious injury or illness resulting in temporary disability
Property damage disruptive but less severe than above
Minor injury or illness that is non-disabling
Property damage that is not disruptive
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110-007-06-IGDO © 2015, Workplace Safety & Prevention Services (WSPS)
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INSTRUCTIONS FOR INVESTIGATION REPORT
Probability of Reoccurrence
Probability is the likelihood that the hazardous situation or event will occur, and includes the frequency
of occurrences. Using the categories of low, medium, and high, ask questions related to the hazard to
determine what you feel the probability of it occurring may be. Some questions to ask are:
1. How many people are exposed to the hazard?
2. How frequent is the exposure to the hazard situation?
3. What are the current control measures?
a. Low = at the source
b. Medium = along the path
c. High = at the worker
4. How many control measures are in place?
a. Low = multiple
b. High = none
5. What is the quality of the control measures?
a. Low = legal requirements, standards/best practices, monitored
b. High = minimum legal requirements are not being met
Section F:
Describe where the event occurred (location, building, etc.) and what happened. Include as much
detail as possible in order to aid in determining proper recommendations on preventing this incident
in the future.
For Example:
Worker was at the north end of the garage at 2:00 p.m. performing regular duties. Worker got splashed with
chemical XYZ and got some in both eyes. At that time he was pouring 1.5L of chemical XYZ into container
and was not wearing his safety goggles, as required.
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110-007-06-IGDO © 2015, Workplace Safety & Prevention Services (WSPS)
1 877 494 WSPS (9777) | 905 614 1400 | www.wsps.ca
INSTRUCTIONS FOR INVESTIGATION REPORT
Section G:
List all the immediate causes in box 25. Immediate causes are substandard actions or inactions and
substandard conditions that contributed to the incident. Examples may include: operating equipment
without authority or inadequate or improper protective equipment. Examples are provided on the back
of the form (#25A). This is not an exhaustive list. Be specific. Provide as many details as possible when
outlining the immediate causes.
List all the underlying causes in box 26. Underlying causes relate to the immediate causes identified in
the investigation. Underlying causes are the underlying factors that explain why the immediate causes
were allowed to exist or occur. Examples may include: inadequate purchasing or inadequate work
standards. Examples are provided on the back of the form (#26A). Be specific. Provide as many details as
possible when outlining the underlying causes. Ensure all immediate causes can be traced back to at least
one underlying cause.
Section H:
In this section, determine the level at which all Program Elements are at:
P – Program Element requires implementation
S – The existing standards are inadequate and require revision
C – Compliance with standards are inadequate
Section I:
List all actions that have been taken or need to be taken to prevent a similar incident from occurring.
Recommendations must relate to the underlying causes identified in box #26. All recommendations
must be clear and specific and outline the name of the person responsible for taking action and the
expected completion date. Once the action has been completed, indicate the completion date in the
appropriate column.
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110-007-06-IGDO © 2015, Workplace Safety & Prevention Services (WSPS)
1 877 494 WSPS (9777) | 905 614 1400 | www.wsps.ca
INSTRUCTIONS FOR INVESTIGATION REPORT
Section J:
In this section, the Reviewer shall briefly write down his/her reaction of the investigators findings of the
basic causes of the incident and remedial actions for future prevention. Please note: whoever plays the part
of the reviewer and investigator depends on the company procedure and policy. It should be stressed that
this process is to be an unbiased one, and therefore, any personal reactions to the interviewer should be
ignored. Only responses to the report and the analysis itself should be made.
© Workplace Safety & Prevention Services 2015. Workplace Safety & Prevention Services (WSPS) grants permission to approved
end users to reproduce this document in whole or in part, provided its intended use is for non-commercial, educational purposes
and that full acknowledgement is given to the WSPS. Approved end users are firms registered with the Workplace Safety and
Insurance Board. WSPS reserves the right to extend this permission to other stakeholders and interested parties by express written
permission upon application. WSPS extends no warranty to materials amended or altered by the end user. Under no circumstances
is this document, or any portion thereof, to be duplicated for purposes of sale or for external reproduction or distribution.
(Sample WSPS acknowledgement, “Reproduced or adapted from name of solution with permission of Workplace Safety &
Prevention Services, Mississauga, Ontario.”)
The information contained in this reference material is distributed as a guide only. It is generally current to the best of our
knowledge as at the revision date, having been compiled from sources believed to be reliable and to represent the best current
opinion on the subject. No warranty, guarantee, or representation is made by WSPS as to the absolute correctness or sufficiency
of any representation contained in this reference material. WSPS assumes no responsibility in connection therewith; nor can it be
assumed that all acceptable safety measures are contained in this reference material, or that other or additional measures may not
be required in particular or exceptional conditions or circumstances.
Revised: March 2015
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110-007-06-IGDO © 2015, Workplace Safety & Prevention Services (WSPS)
1 877 494 WSPS (9777) | 905 614 1400 | www.wsps.ca