Incident / Near Miss Investigation Report

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Appendix 11 – Incident/Near Miss Investigation Report Form

[ Church name ] church

Incident/near miss investigation report

Instructions: This form should be completed for all incidents requiring investigation. The level of investigation should be proportionate to the severity of the incident.

Figure -Incident Report

Incident details

Field	Information
Incident Report Number:
Investigation Number:
Date of Incident:
Time of Incident:
Date Investigation Started:
Investigation Completed:

Investigation team

Role	Name	Position	Contact
Lead Investigator
Team Member
Team Member
External Advisor

Incident summary

Type of Incident: InjuryIllnessNear MissProperty DamageEnvironmentalOther

Severity Level: MinorModerateSeriousMajorCatastrophic

Location:

Activity Being Undertaken:

Brief Description:

Investigation methodology

Investigation Methods Used: Site inspectionInterviewsDocument reviewPhotographyMeasurementsTestingExpert consultationOther

Evidence Collected: PhotographsMeasurementsSamplesDocumentsEquipmentWitness statementsOther

Site inspection findings

Physical Conditions at Time of Incident:

Weather:

Lighting:

Noise Levels:

Housekeeping:

Equipment Condition:

Environmental Factors:

Site Sketch/Diagram: (Attach if applicable)

Photographs Taken: YesNo Number

Witness interviews

Witness 1

Name:

Position:

Contact:

Summary of Statement:

Witness 2

Name:

Position:

Contact:

Summary of Statement:

Witness 3

Name:

Position:

Contact:

Summary of Statement:

Sequence of events

Timeline of Events Leading to Incident:

Time	Event	Source

Causal analysis

Immediate causes (Unsafe Acts and Conditions)

Unsafe Acts: Operating without authorityFailure to warn or secureOperating at unsafe speedMaking safety devices inoperativeUsing defective equipmentUsing equipment unsafelyFailure to use PPE properlyImproper lifting or positioningTaking unsafe position or postureWorking on moving/dangerous equipmentOther

Unsafe Conditions: Inadequate guards or barriersDefective tools, equipment, or materialsCongestion or restricted actionInadequate warning systemsFire and explosion hazardsPoor housekeepingHarmful environmental exposureInadequate lightingExcessive noiseOther

Underlying causes (Basic Causes)

Personal Factors: Inadequate capability/skillInadequate knowledgeStress (physical or mental)Inadequate motivationOther

Job Factors: Inadequate leadership/supervisionInadequate engineeringInadequate purchasing/procurementInadequate maintenanceInadequate tools and equipmentInadequate work standardsWear and tearOther

Root causes (Management System Failures)

Policy/Standards: Inadequate programInadequate program standardsInadequate compliance with standards

Training: Inadequate initial trainingInadequate refresher trainingInadequate training records

Communication: Inadequate hazard communicationInadequate safety meetingsInadequate safety promotion

Other Management Factors:

Contributing factors

Human Factors: FatigueDistractionComplacencyTime pressureLack of experiencePoor communicationOther

Organizational Factors: Inadequate proceduresPoor safety cultureResource constraintsCompeting prioritiesChange managementOther

Environmental Factors: Weather conditionsLightingNoiseTemperatureWorkspace designOther

Findings and conclusions

Primary Cause:

Contributing Causes:

Key Findings:

Could This Incident Have Been Prevented? YesNo

Explanation:

Corrective actions

Immediate Actions (Already Taken)

Action	Responsibility	Date Completed	Effectiveness

Short-term Actions (0-3 months)

Action	Responsibility	Target Date	Resources Required	Priority

Long-term Actions (3+ months)

Action	Responsibility	Target Date	Resources Required	Priority

Lessons learned

What Worked Well:

What Could Be Improved:

Recommendations for Similar Activities:

Communication of Lessons Learned: Staff meetingNewsletterTraining sessionPolicy updateOther

Follow-up actions

Monitoring Plan:

Action	Monitor Method	Frequency	Responsibility

Review Date for Effectiveness:

Responsible Person:

Investigation sign-off

Investigation Completed By:

Lead Investigator:

Signature: Date:

Investigation Reviewed By:

Health & Safety Champion:

Signature: Date:

Investigation Approved By:

Senior Pastor/Manager:

Signature: Date:

Distribution

Report Distributed To: Church LeadershipHealth & Safety CommitteeAffected StaffInsurance CompanyWorkSafe (if required)Other

Distribution Date:

Distributed By:

Closure

All Actions Completed: YesNo

Effectiveness Verified: YesNo

Investigation Closed By:

Closure Date:

Final Comments:

Finished?

Your name *

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