Incident and Near Miss Investigation Report Date of incident* Date Format: MM slash DD slash YYYY Description of incident*Cause*What was the indirect or direct cause? (check all that apply) Operating equipment without training Failure to use PPE Failure to follow procedures Housekeeping Using equipment improperly Using defective tools / equipment Horseplay Failure to secure Other Other indirect or direct cause*Root*What was the root cause of the incident? (Check all that apply) Design of workspace Not enough electrical outlets Physical stress Improper motivation Lack of skill Inadequate orientation Inadequate training Inadequate tools Other Other Root Causes*Attachments*What type of informational attachments are filed separately for this incident? (Check all that apply) Photos Training records Video Diagrams / sketches other Other Attachments*Actions*What corrective actions are required for this incident? (List one per line)
