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Page 1: Incident Investigation Report - risksupportrisksupport.org.au/resources/Documents/Incident Investigation... · Incident Investigation Report Incident Report ID No.: TEMPLATE Section

Incident Investigation ReportIncident Report ID No.:

TEMPLATE

Section 1: Details of person completing the report

Last name: First name: Report date: / /

Department:Contact phone no.:

Position:

Section 2: Details of investigation team

Last name: First name: Position:

Last name: First name: Position:

Last name: First name: Position:

Section 3: Details of persons interviewed (attach records of interview)

Last name: First name:Contact phone no.:

Last name: First name:Contact phone no.:

Last name: First name:Contact phone no.:

Section 4: Incident description (what happened)

Provide a summary of the facts of the incident:

Section 5: Contributing factors (why it happened)

List all contributing factors to the incident (human, environmental, systems, design):

• lack of supervision • fatigue

Page 2: Incident Investigation Report - risksupportrisksupport.org.au/resources/Documents/Incident Investigation... · Incident Investigation Report Incident Report ID No.: TEMPLATE Section

Section 6: Risk identification & analysis

1. Identify all risks that are relevant to the incident

2. Identify any existing controls in place to manage the risks

3. Are the existing controls effective?

e.g. Inadequate supervision of inexperienced workers operating plant resulting in serious injury

e.g. Plant is security protected limiting operation to experienced staff

Yes No

Yes No

Yes No

Yes No

Yes No

If no controls in place or controls not effective complete Section 7

Section 7: Corrective action plan

What actions have been undertaken or will be undertaken to prevent the incident from reoccurring?

Corrective action Responsibility Due date Completed date

e.g. Managers to receive biannual training reminding them of their supervision responsibilities

HR officer 1/01/2015 1/12/2014

Section 8: Incident investigation notification

Completed report has been provided to:

WHS Officer

Executive Group

Catholic Education Office

Bishop

Manager / Supervisor

Other (please specify) _______________________

Notes:

A copy of the report has been securely stored and archived.

CCI RM303 1014

1300 660 827 or [email protected] you would like further information please contact the risksupport Helpdesk on:

www.risksupport.org.au Catholic Church Insurance Limited, ABN 76 000 005 210, AFSL no. 235415, GPO Box 180 Melbourne 3001