Workplace Incident Investigation Rubric
Incident Details |
Date and Time | [Month Day, Year, Time] |
Location | [Warehouse B, Section 4] |
Brief Description | [Forklift overturned while maneuvering in a narrow aisle.] |
Immediate Actions |
First Aid/Medical Treatment | [First aid administered on-site; employee taken to hospital for further examination.] |
Area Secured | [Yes] |
1. Incident Classification
Type of Incident
Severity Level
2. Hazard Identification
Types of Hazards
Specific Hazards Identified
3. Cause Analysis
Immediate Causes
Underlying Causes
Contributing Factors
4. Witness Information
Witness Details
Interview Summaries
5. Evidence Collection
Types of Evidence
6. Risk Assessment
Likelihood of Recurrence
Impact on Health and Safety
7. Corrective Actions
Short-term Measures
Long-term Solutions
8. Follow-Up Actions
Implementation of Recommendations
Monitoring and Review
9. Reporting and Documentation
Report Quality
Documentation
10. Communication and Feedback
Communication with Parties
Feedback Mechanisms
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