Workplace Incident Investigation Rubric

Incident Details
Date and Time	[Month Day, Year, Time]
Location	[Warehouse B, Section 4]
Brief Description	[Forklift overturned while maneuvering in a narrow aisle.]
Immediate Actions
First Aid/Medical Treatment	[First aid administered on-site; employee taken to hospital for further examination.]
Area Secured	[Yes]

1. Incident Classification

Type of Incident

• Slip, Trip, Fall

• Equipment Failure

• Other (Specify)

Severity Level

• Minor

• Moderate

• Severe

• Catastrophic

2. Hazard Identification

Types of Hazards

• Physical

• Chemical

• Biological

• Ergonomic

Specific Hazards Identified

• Narrow Aisles

• Improperly Stacked Inventory

3. Cause Analysis

Immediate Causes

• Human Error

• Equipment Malfunction

Underlying Causes

• Inadequate Training

• Poor Maintenance

Contributing Factors

• Environmental Conditions (Cluttered Aisles)

4. Witness Information

Witness Details

• John Doe, Co-worker

• Jane Smith, Supervisor

Interview Summaries

• Both witnessed the forklift struggling to maneuver before tipping over.

5. Evidence Collection

Types of Evidence

• Photographic (pictures of the scene)

• Documents (Forklift maintenance log)

6. Risk Assessment

Likelihood of Recurrence

• High

• Medium

• Low

Impact on Health and Safety

• High

• Medium

• Low

7. Corrective Actions

Short-term Measures

• Reorganize inventory to widen aisles.

Long-term Solutions

• Implement comprehensive forklift operation training.

8. Follow-Up Actions

Implementation of Recommendations

• Completed

• In Progress

Monitoring and Review

• Monthly safety inspections scheduled.

9. Reporting and Documentation

Report Quality

• Clarity

• Completeness

Documentation

• All Steps Documented

10. Communication and Feedback

Communication with Parties

• Employees

• Management

Feedback Mechanisms

• Established

• Effective

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