Workplace Safety Incident
Root Cause Analysis Report

Incident Information

Date of Incident
Time of Incident
Location
Reported By
Department

Incident Description

Immediate Actions Taken

Investigation Details

People Interviewed
Evidence Collected
Timeline of Events

Root Cause Analysis

Direct Cause
Underlying Cause(s)
Root Cause(s)

Corrective Actions

Immediate Corrective Actions
Long-term Preventive Actions
Responsible Person(s)
Target Completion Date

Review & Sign-off

Investigator Name & Signature
Date
Manager Review & Signature
Date