Safety Incident Investigation Report
1. Basic Information
Date of Incident
Time of Incident
Location
Reported By
Department/Unit
2. Incident Description
Summary of Incident
Detailed Description
3. Chemicals Involved
Name
Quantity
State (Solid/Liquid/Gas)
Hazards
4. People Involved
Name
Role
Injury/Exposure
5. Immediate Actions Taken
6. Root Cause Analysis
Description of Root Cause
7. Corrective and Preventive Actions
Actions to Prevent Recurrence
8. Attachments/Supporting Documents
List Attachments
9. Investigator Details
Name
Date