Tool 114 Incident Investigation

RAINBOW CLUB AUSTRALIA

Incident Investigation
Name of person conducting the incident investigation:
Incident number:
Date incident occurred: Date report made:
Did the incident cause harm to: [please tick the relevant item/s]
Person/s Assets Environment Organisation’s reputation
Attach a copy of the Initial Incident Report  □ Yes
Witness statement: [Please attach a separate statement if required] 

 

 

 

Potential causes:

  • Not following procedure/no procedure in place
  • System failure
  • Environmental factors  [please provide detail]
  • Staff/client behaviour
  • Defective equipment
  • Inappropriate conduct
  • Failure to use Personal protection Equipment (PPE)/no PPE available
  • Hazards present
  • Other (explain):

 

Corrective action (tick actions taken to prevent reoccurrence) 
Corrective action:

□ Improved work procedures

□ Improved communication about work procedures

□ Staff training

□ Removal of hazards/harm minimisation related to hazard/s

□ Equipment repair/replacement

□ System modification/improvement

□ Improved inspection procedures

□ Other (please detail):

 

 

 

 

 

Describe all actions taken: 

 

 

 

 

Investigated by:Name:

Position:

Signature:

Date:

 

Monitoring and Review

Monitoring and review of corrective action will be undertaken by [insert name of staff member] on [insert date].

 

Incident management register

 

Entered on register by …………………………………………………

 

Date …………………………