Radwell Incident Investigation Report

i

Report header

Type of report, when it happened, and where.

This is a report of * (check all that apply)

Date of Incident *

Time of Incident

Date Reported

Time Reported

Division

Company Name

Company City / State

Site (facility)

Reported to

Location of incident (address)

Police Report # (if applicable)

Responding Officer name / contact info

1

Employee involved in incident

Do not include the employee name for acts of violence.

Name

Job Title

Part of Body (check all that apply)

Nature of Injury — most serious (check all that apply)

If "Other", explain

Was the employee given first aid?

Explain

If medical treatment provided, where was the employee treated? (check all that apply)

Transported by ambulance?

Medical Provider(s) — name, address, phone

2

Describe the incident

Tell the full story of what happened.

Summary *

Describe step-by-step what happened before, during, and after. Include any vehicles, machines, tools, parts, or materials involved.

What part of the workday did it occur? (check all that apply)

If "Other", explain

Was the employee performing the job alone?

If no, who else was involved / present?

How long has the employee been doing this job?

What safety equipment was being used? (check all that apply)

List equipment

Was proper safety equipment worn?

If no, explain why

2a

Acts of violence

Shown because "Act of Violence" is checked in the header.

Person(s) involved (check all that apply)

If "Other", explain

Type of incident (check all that apply)

If physical attack with a weapon — indicate weapon

If animal attack — describe

Was security or law enforcement contacted?

Response

3

Why did the incident happen?

Identify the unsafe conditions and unsafe acts that contributed.

Does an unsafe CONDITION exist that contributed?

Describe the unsafe condition

Were there any unsafe ACTS that contributed?

Describe the unsafe acts

Why did the unsafe condition exist?

Why did the unsafe act occur?

4

How can future incidents be prevented?

Be specific, and assign corrective actions with owners and dates.

How could the incident have been prevented? BE SPECIFIC

Recommended Corrective Action(s)

5

Who completed and reviewed this form

Investigator and supporting documents.

Name of Investigator *

Job Title

Date Completed

Additional Documents (check and number each)

S

Classification — For Safety Use

Completed by EHS.

Incident Classification *

Cause of Injury

Incident #

W/C Carrier Claim #

Date Report filed with W/C Carrier

📷

Photos (optional)

Up to 5. Scene, equipment, PPE, hazard — compressed on device.

📷 Add photo

Investigation submitted