Date:	Date.	Document ID#:	(pvid)-(cntrtrID)-(base code)-IIS-(yymmdd)-V(version)	Version #:
PVID#:	Contractor/Company Name:	Contractor ID:
Camp/Base:	Choose a Camp/Base	Location:	Site:

(Date and Time of Event)

(Corresponding JARS Event Number)

(Brief Event Title)

Event reported by:
Incident investigator/s:
Report writer:

To be completed for:

Events that are not notifiable to WorkSafe;

Events that do not require an ICAM Report.

(Short Form investigations may be conducted by only one person)

For other events use "Incident Investigation Report (ICAM)".

Incident Information

Incident Description

(Enter description)

Incident Type

(tick appropriate box)

Injury	Near miss	Environmental
Property damage	Equipment failure	Electrical
Other	(specify if ‘other’)

Actual Consequence

(tick appropriate box)

None	Minor	Moderate	HPE

Potential Consequence

(tick appropriate box)

Minor	Moderate	HPE

Workers and others interviewed

Name	Position	Company / Organisation

What happened?

(Describe what happened)

Immediate Action/s Taken

XXX

XXX

What caused the Incident?

Immediate causes

(substandard/unsafe acts, practices or conditions)

XXX

Contributing Factors

Contributing factors highlighted in this investigation report include:

XXX

XXX

Root Cause/s & Conclusion

Root Cause/s

Key findings in this investigation highlighted the following:

(Root cause 1): (description)

(Root cause 2): (description)

Conclusion

‘This incident took place as a result of….’

Corrective Action Plan

S/No	Action	Hierarchy of Control	Responsible Person	Target Date
1
2
3

Evidence / Appendices

(List and attach all evidence gathered as part of the investigation, e.g. photos, memos, JSA’s, statements)

Appendix #	Description	Collected by

Comments and Sign-off

Name	Signature	Date
(Contractor H&S Manager)
(Engineer to Contract)
(DEI RHSS)

I am satisfied that all reasonable steps have been taken to thoroughly investigate this incident, including identifying any management failures, systems failures, and identify & assign appropriate corrective actions. Name: (Print) Position: (Contractor Project Manager) Signature: Date:

The process for Sign-off:

Ensure the workers involved have reviewed the investigation

Sign off should include the DEI RHSS and/or DEI DD H&S, Contractor Group Safety Manager and Contractor PM

Appendices

Note:

1.	Some of the following items may form part of this report - add or remove as required.

2.	Lessons Learnt must be completed for all investigations and submitted to the DEI H&S office for communication to the wider organisation, where applicable.

3.	A Safety Alert may be required on a case-by-case basis for some Short Form investigations

Safety Alert (where applicable)

Lessons Learnt

Site Photos

Work Pack/Instructions/diagrams

Copy of Team briefing/Tailgate

Documented Instructions, JSA’s, SWMS, etc

Permits