[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-252807-105":53,"doc-detail-252807-en":127},{"code":4,"msg":5,"data":6},0,"success",[7,14,19,24,29,34,39,44,49],{"id":8,"doc_module":9,"doc_module_name":10,"category_name":11,"show_sort_weight":12,"slug":13},11,1,"Template","Presentations",90,"presentations",{"id":15,"doc_module":9,"doc_module_name":10,"category_name":16,"show_sort_weight":17,"slug":18},12,"Resumes",80,"resumes",{"id":20,"doc_module":9,"doc_module_name":10,"category_name":21,"show_sort_weight":22,"slug":23},14,"Invoices",70,"invoices",{"id":25,"doc_module":9,"doc_module_name":10,"category_name":26,"show_sort_weight":27,"slug":28},15,"Posters",60,"posters",{"id":30,"doc_module":9,"doc_module_name":10,"category_name":31,"show_sort_weight":32,"slug":33},16,"Social Media",50,"social-media",{"id":35,"doc_module":9,"doc_module_name":10,"category_name":36,"show_sort_weight":37,"slug":38},17,"Forms",40,"forms",{"id":40,"doc_module":9,"doc_module_name":10,"category_name":41,"show_sort_weight":42,"slug":43},18,"Letters",30,"letters",{"id":45,"doc_module":9,"doc_module_name":10,"category_name":46,"show_sort_weight":47,"slug":48},21,"Paper Templates",5,"papers-templates",{"id":50,"doc_module":9,"doc_module_name":10,"category_name":51,"show_sort_weight":4,"slug":52},158,"General","general-158",{"code":4,"msg":54,"data":55},"ok",{"site_id":56,"language":57,"slug":58,"title":59,"keywords":60,"description":61,"schema_data":62,"social_meta":120,"head_meta":122,"extra_data":124,"updated_unix":126},105,"en","incident-investigation-form-workplace-safety","Incident Investigation Form - Workplace Safety","","Incident Investigation Form for reporting and analyzing workplace incidents involving employee injury, near miss events, or property damage. The form sets clear submission timelines, instructs completion and signing, and requires generating copies for lost time injury investigations. It captures employee and accident details, narrative and contributing factors, PPE usage and property damage information, witness contact data, checked cause categories, and root causes. It also records corrective actions, training, work order or project requests, prevention measures, and review/investigation sign-off dates.",{"@graph":63,"@context":119},[64,80,102],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/incident-investigation-form-workplace-safety/252807/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/incident-investigation-form-workplace-safety/252807.png","ImageObject",442,249,{"name":88,"@type":89},"Jasmine","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-29","2026-09-13",true,{"@type":98,"interactionType":99,"userInteractionCount":101},"InteractionCounter",{"@type":100},"ViewAction",10,{"@type":103,"mainEntity":104},"FAQPage",[105,111,115],{"name":106,"@type":107,"acceptedAnswer":108},"How quickly must the Safety Specialist be notified after an incident?","Question",{"text":109,"@type":110},"Notify the Safety Specialist within 24 hours of the incident (employee injury, near hit, or property damage).","Answer",{"name":112,"@type":107,"acceptedAnswer":113},"When must the completed incident investigation form be submitted?",{"text":114,"@type":110},"Submit the completed form to the designated Safety Office within 3 working days of the accident or incident.",{"name":116,"@type":107,"acceptedAnswer":117},"What information is required about causes and corrective actions?",{"text":118,"@type":110},"The form requires checking contributing causes (direct/immediate and root causes), providing a detailed narrative and PPE/property damage details, and documenting corrective actions, remedial training, and any work order/project request details to prevent recurrence.","https://schema.org",{"og:url":78,"og:type":121,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":123,"canonical":78},"index,follow",{"doc_id":125,"site_id":56},252807,1790928281,{"code":4,"msg":5,"data":128},{"doc_id":125,"user_id":129,"nickname":88,"user_avatar":130,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":101,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":73,"language":136,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":61,"update_tm":140,"read_time":9},2336478487870,"https://ap-avatar.wpscdn.com/davatar_085a072bc5b1113ac321206ff7593b45","INCIDENT INVESTIGATION FORM  \nDirections for Completion:  \n1. Notify Safety Specialist within 24 hours of incident(Employee Injury, Near Hit, Property Damage) .  \n2. Complete and submit this form to the designated Safety Office within 3 working days of the accident/Incident.  \n3. Please remember to sign and date the form.  \n4. Make five copies of this form for any Lost Time Injury Investigations.  \nEmployee Injury Near Hit Incident Property Damage  \nSubmit completed form to one of the following locations:  \nPhysical Plant Safety Office  \n103 Physical Plant Building University Park, PA 16802  \nAuxiliary & Business Services Safety Office  \n127 Johnston Commons University Park, PA 16802  \nEmployee Data  \nEmployee Name:   Today's Date:   Department:   Job Title:   Work Area:   Shift:    \nLength of Employment at PSU:   Full Time Part Time Wage  \nLocation of Accident (Building, Room Number):   Date of accident:   Time of accident:   AM PM Claim Number:   Supervisor Name:  Signature:   \nAccident Data/Contributing Factors  \nDetailed narrative of how incident occurred:  \nDescription of Pictures Taken:  \nWhat was employee doing just prior to accident (job task, include any tools or machinery used):  \nBody part injured and type of injury (be specific):  \nIf it is a Near Hit, descibe the potential injury/damage:  \nWeather conditions at time of accident:   Visibility/Lighting (ex. poor, work lights, etc.):   Type and condition of floor surface (ex. concrete, wet):    \nPPE required for job:    \nWas PPE being utilized? Yes No  \nWas there any damage to property or equipment? Yes No  \nExplain:   Name(s) of witness(es):   Phone\\#    \nName(s) of witness(es):   Phone\\#    \nCauses  \nPLEASE CHECK ALL OF THE FOLLOWING WHICH CONTRIBUTED TO THE INJURY OR ILLNESS  \nDirect/ Immediate Causes (supervisor complete)  \nDefective Tools/ Equipment Unaware of potential hazard Unauthorized equipment use  \nUnsafe work Procedures Lack of safety devices Guard removed/ guard needed  \nInsufficient procedures Not employees normal job Poor housekeeping  \nNot following procedures Improper use of tools Violated safety rule  \nImprovising/ shortcuts Proper tools not available Not wearing proper equipment  \nRoot Causes  \nEmployee unaware of hazard Failure to recognize unsafe act Equipment maintenance  \nComplex procedures Poor attitude Weather Condition(Rain, Snow)  \nUnclear instruction Personality conflict Excessive production pressure  \nInadequate training Lack of training Communication error  \nInadequate comprehension Job design/ workstation layout Lack of employee cooperation Lack of skill/ knowledge Lighting Other, please explain:  \n____________________________  \nCorrective Actions  \nRecommended Engineering control, Training, or Program/policy change:  \nRemedial training given:  \nWas a work order or a project request submitted for solution(s)?  \nPlease provide details of request including job/project number and deadline for completion:  \nWhat action was or should be taken to prevent recurrence?  \nCorrective actions completed? Yes No If no, explain:    \nInvestigated by: Date:    \nReviewed by: Date:","cbCaiu6ynTkMi9fW","https://ap.wps.com/l/cbCaiu6ynTkMi9fW","pdf",782544,"English","# Directions for Completion\n# Employee Data\n# Accident Data/Contributing Factors\n## Detailed narrative and observations\n## PPE and property damage\n# Causes\n## Direct/Immediate Causes\n## Root Causes\n# Corrective Actions\n# Investigated by and Reviewed by","[{\"question\":\"How quickly must the Safety Specialist be notified after an incident?\",\"answer\":\"Notify the Safety Specialist within 24 hours of the incident (employee injury, near hit, or property damage).\"},{\"question\":\"When must the completed incident investigation form be submitted?\",\"answer\":\"Submit the completed form to the designated Safety Office within 3 working days of the accident or incident.\"},{\"question\":\"What information is required about causes and corrective actions?\",\"answer\":\"The form requires checking contributing causes (direct/immediate and root causes), providing a detailed narrative and PPE/property damage details, and documenting corrective actions, remedial training, and any work order/project request details to prevent recurrence.\"}]","Incident Investigation Form - Workplace Safety | PDF",1789262993]