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Incident Investigation Form

Root cause analysis — complete within 5 working days of the incident.

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PAGE 1 OF 2

Investigation Details
Incident Summary
Injury Near Miss Property Damage Environmental Other: _______________
Severity Actual:
Low Med High Critical
Severity Potential:
Low Med High Critical
Brief Description of Incident

Persons Involved

# Name Role / Company Injury / Involvement
1
2
3
4

Timeline of Events

Time Event Description
Immediate Response
First aid provided: Y / N   Details: ___________________
Emergency services called: Y / N
Area secured: Y / N
Regulator notified: Y / N   Ref: _______________
PAGE 1 OF 2  ·  Incident Investigation Form  ·  MapTrack template
Ref no.
Investigator
Incident Investigation - Page 2 of 2
Ref no.
Investigator
5 Whys Analysis
Why 1 (immediate cause)
Why 2
Why 3
Why 4
Why 5 (root cause)
Contributing Factors (ICAM)
Absent / failed defences
Individual / team actions
Task / environmental conditions
Organisational factors
Root Cause Summary

Corrective Actions

# Action Type
(Eliminate / Eng / Admin / PPE)		 Owner Due Date Priority
(H/M/L)		 Status
1
2
3
4
5
Follow-up Verification
Y / N
Notes:

Declaration

I confirm this investigation has been conducted thoroughly, all contributing factors have been analysed, and corrective actions have been identified to prevent recurrence.

Lead Investigator Sign-off
Signature
Print name
Date
Reviewer / Manager Sign-off
Signature
Print name
Date

PAGE 2 OF 2  ·  Incident Investigation Form  ·  MapTrack template  ·  Rev 2026-04
Free template from MapTrack. For digital incident investigations with corrective action tracking and automated follow-up reminders, see maptrack.com