Incident Investigation Conduct Assessment
Evaluate the thoroughness and effectiveness of the incident investigation process.
Incident Title
*
Incident Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Incident Location
*
Type of Incident
*
Please Select
Safety
Security
Environmental
Quality
Other
Brief Description of the Incident
*
Names of Individuals Involved
Investigation Team Members
Assessment of Investigation Steps
*
Rows
Not Performed
Partially Performed
Fully Performed
Incident Scene Secured
1
2
3
Witnesses Interviewed
4
5
6
Evidence Collected
7
8
9
Documentation Completed
10
11
12
Root Cause Identified
13
14
15
Corrective Actions Proposed
16
17
18
Root Cause Analysis Method Used
5 Whys
Fishbone Diagram
Fault Tree Analysis
Other
Effectiveness of Corrective Actions
1
2
3
4
5
Overall Assessment of the Investigation
*
Poor
1
2
3
4
Excellent
5
1 is Poor, 5 is Excellent
Recommendations for Improvement
Assessor's Name
*
First Name
Last Name
Date of Assessment
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit Assessment
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