Checklist template

Incident Investigation

A ready-to-use checklist with 59 items in 8 sections, covering Investigation Administration, Evidence Collection & Scene Analysis, Worker Context & Training History, Equipment & Technology Factors, The "Five Whys" Root Cause Analysis, Safety Management System (SMS) Check and more. Use it as-is in Bindy, or adapt it to your own standards in minutes.

  • 8 Sections
  • 59 Items
  • 42 Yes / No checks
  • 8 Scored ratings
  • 1080 Points

Use this template How audits work

1. Investigation Administration 9 items

  1. Date Investigation Commenced: Date
  2. Lead Investigator Name & Title: Comments
  3. Incident Reference Number (from Initial Report): Comments
  4. Was the investigation launched within 24 hours of the event? Yes / No 30 pts
  5. Was the investigation team comprised of at least two people? Yes / No 10 pts
  6. Was the immediate supervisor of the area interviewed? Yes / No 15 pts
  7. Was the injured party (if applicable) interviewed separately? Yes / No 15 pts
  8. Are witness statements signed, dated, and attached? Yes / No 20 pts
  9. Investigation Timeliness: Rating
    • Immediate/High Priority 20 pts
    • Delayed (>48 hours) 10 pts
    • Retrospective/Late 0 pts

2. Evidence Collection & Scene Analysis 8 items

  1. Was the scene preserved in its original state for the walk-through? Yes / No 40 pts
  2. Were physical measurements of distances/weights recorded? Yes / No 15 pts
  3. Was CCTV or dashcam footage reviewed and archived? Yes / No 30 pts
  4. Were the environmental conditions (lux levels, decibels) tested? Yes / No 20 pts
  5. Was the specific tool or machine involved tagged "Out of Service"? Yes / No 35 pts
  6. Were "Before and After" photos of the corrected hazard taken? Yes / No 10 pts
  7. Did the team check for similar hazards in nearby departments? Yes / No 15 pts
  8. Quality of Evidence: Rating
    • High (Video/Forensic) 25 pts
    • Medium (Interviews only) 12 pts
    • Low (Speculative) 0 pts

3. Worker Context & Training History 7 items

  1. Did the individual have >6 months of experience in this role? Yes / No 5 pts
  2. Does the employee’s file contain a signed copy of the specific SOP? Yes / No 25 pts
  3. Was the employee current on all safety "Toolbox Talks"? Yes / No 15 pts
  4. Was a pre-shift safety huddle held on the day of the incident? Yes / No 10 pts
  5. Was the employee working their first 4 hours of the shift? Yes / No 10 pts
  6. Did the employee confirm they understood the task requirements? Yes / No 15 pts
  7. Training Efficacy: Rating
    • Fully Trained/Competent 20 pts
    • Training Gaps Identified 10 pts
    • Untrained for Task 0 pts

4. Equipment & Technology Factors 7 items

  1. Was the equipment used for its specific designed purpose? Yes / No 25 pts
  2. Are all safety guards and interlocks functional? Yes / No 50 pts
  3. Is the equipment’s Preventive Maintenance (PM) log current? Yes / No 30 pts
  4. Was there a previous repair request for this item in the last 30 days? Yes / No 15 pts
  5. Were manufacturer’s warning labels legible and visible? Yes / No 10 pts
  6. Was the equipment free of unapproved modifications or "hacks"? Yes / No 40 pts
  7. Mechanical Contribution: Rating
    • Equipment Not a Factor 20 pts
    • Contributing Failure 10 pts
    • Primary Cause of Event 0 pts

5. The "Five Whys" Root Cause Analysis 8 items

  1. Why did the incident happen? (Direct Cause): Comments
  2. Why did that occur? (Secondary Cause): Comments
  3. Why did that occur? (Systemic Level): Comments
  4. Why did that occur? (Management Level): Comments
  5. Why did that occur? (Root Cause): Comments
  6. Does the Root Cause relate to a process or policy failure? Yes / No 30 pts
  7. Did the analysis look beyond "Human Error" as the final answer? Yes / No 40 pts
  8. RCA Depth: Rating
    • Systemic Root Identified 25 pts
    • Surface Level Only 10 pts
    • No Root Identified 0 pts

6. Safety Management System (SMS) Check 6 items

  1. Is there a Job Hazard Analysis (JHA) on file for this specific task? Yes / No 25 pts
  2. Has this specific incident occurred before at this location? Yes / No
  3. Was the hazard identified in the previous month’s safety audit? Yes / No 15 pts
  4. Was the supervisor present and supervising at the time? Yes / No 10 pts
  5. Is there a clear "Stop Work Authority" policy communicated? Yes / No 20 pts
  6. Management Oversight: Rating
    • Strong/Proactive 20 pts
    • Moderate/Reactive 10 pts
    • Weak/Non-Existent 0 pts

7. Preventive Actions & Hierarchy of Controls 8 items

  1. Elimination: Can the hazard be removed entirely? Yes / No 50 pts
  2. Substitution: Can a safer material or machine be used? Yes / No 40 pts
  3. Engineering: Can we install a physical barrier or guard? Yes / No 30 pts
  4. Administrative: Do we need to rewrite the SOP or retrain? Yes / No 20 pts
  5. PPE: Is more or better protective gear required? Yes / No 15 pts
  6. Is there a firm "Target Date" for all corrective actions? Yes / No 20 pts
  7. Has the budget been approved for these improvements? Yes / No 10 pts
  8. Control Effectiveness: Rating
    • Permanent Fix (Elimination) 30 pts
    • Temporary Fix (Admin/PPE) 15 pts
    • No Action Taken 0 pts

8. Verification & Close-Out 6 items

  1. Has a follow-up inspection been scheduled for 30 days out? Yes / No 20 pts
  2. Were the findings shared with the Health & Safety Committee? Yes / No 15 pts
  3. Has the "Lessons Learned" been shared with other store/site leads? Yes / No 20 pts
  4. Is the investigation file complete with all photos and notes? Yes / No 15 pts
  5. Investigation Status: Rating
    • Closed - All Actions Done 20 pts
    • Open - Monitoring 10 pts
    • Stalled/Inactive 0 pts
  6. Executive Summary and Final Determination: Comments

About this template

This checklist is part of the Bindy template library. Yes / No checks score 1 point when met; ratings score the points shown for each option. The overall score is the percentage of points earned, with N/A answers excluded. In Bindy you can add photos, assign corrective actions, require sign-off and compare results across sites.

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