HSEQ | PSI Engineering

Incident Overview

Date of Incident

Time of Incident

Location of Incident

Site

Brief Summary of Incident

Severity Level

Entry 1

Name

Position

Employee or Contractor?

Details of Injury/Illness (if applicable)

Were witnesses present?

Type of Incident

Suspected Root Cause Category

Contributing Factors

What immediate actions were taken?

Was medical attention required?

Was evacuation required?

Was the area secured?

Lead Investigator Name

Date Investigation Started

Preliminary Findings

Planned Corrective Actions

Incident Photos

Accepted types: PDF, JPG/JPEG, PNG, DOC/DOCX, and XLS/XLSX. Files are checked before they are accepted.

Witness Statements (if any)

Accepted types: PDF, JPG/JPEG, PNG, DOC/DOCX, and XLS/XLSX. Files are checked before they are accepted.

Reported by (Name)

Digital Signature or Confirmation