Incident / Near-Miss Investigation Report

Root-Cause Investigation & Corrective-Action Record | EHS Community Template

SECTION 1 — INCIDENT CLASSIFICATION

InjuryIllnessNear-Miss / Close CallProperty DamageEnvironmental ReleaseVehicle / Equipment Accident

US: OSHA recordable (29 CFR 1904.7)?

☐ Yes☐ No☐ Under Review

Canada: reportable to your OHS regulator or workers' compensation board?

☐ Yes☐ No☐ Under Review

Severity (Actual / Potential)

☐ First Aid☐ Medical Treatment☐ Lost Time☐ Fatality

SECTION 2 — BASIC INFORMATION

Date of Incident

Time of Incident

Date Reported

Report Completed By

Location (Building / Area / Equipment)

Department / Shift

Supervisor at Time of Incident

SECTION 3 — INJURED / INVOLVED PERSON(S)

Name	Job Title	Dept.	Employee / Contractor	Time on Shift	Time on Task	Body Part Injured

Medical Treatment Provided / Facility

Work Status (Full Duty / Restricted / Lost Time)

SECTION 4 — INCIDENT DESCRIPTION

Describe exactly what happened (who, what, where, when, how — facts only):

Task being performed at time of incident:

Equipment / materials / chemicals involved:

SECTION 5 — ROOT CAUSE ANALYSIS (5-Whys)

Ask "Why did this happen?" at least 5 times to reach the underlying system cause. Stop at the level where a corrective action can be taken.

Why #	Question Asked	Answer / Finding
1
2
3
4
5

Root Cause(s) Identified:

SECTION 6 — CONTRIBUTING FACTORS

Inadequate trainingProcedure not followedNo procedure existedInadequate supervision Equipment defectInadequate guardingEnvironmental conditionTime pressure FatigueInadequate PPECommunication failureOther: ________________

SECTION 7 — CORRECTIVE ACTIONS

#	Corrective Action	Type (Eng / Admin / PPE)	Responsible Person	Due Date	Completion Date
1
2
3
4

SECTION 8 — WITNESS STATEMENTS

Witness Name	Title	Statement Summary

Investigator Signature

Supervisor Signature

EHS Manager / Safety Officer

Management Review Date

This template is provided for educational purposes by EHS Community (ehscommunity.com). US federal OSHA: 29 CFR Part 1904 covers recording and reporting injuries and illnesses, not investigations; some states require investigations (for example Oregon, OAR 437-001-0760). Keep the OSHA 300 Log, 300A summary and 301 incident reports (or equivalent forms) for 5 years after the end of the year they cover (29 CFR 1904.33); if you use this report as your 301 equivalent, keep it for 5 years. In Canada, investigation, reporting and retention rules are set by your province or territory, or by the Canada Labour Code for federally regulated workplaces.