Investigation Performed By:(your name here)

Regarding:(date of incident - Subdivision – Type of Accident/Incident/Injury)

report prepared:(date)

2

Incident Fact SheetProject: XXXXXXXDivision: XXXXXXXXSubdivision: XXXXXXXXXPhysical Location: (near city, state)Actual location of Incident: (example: CP Midland, MP 234.9, County Road 25)Date & Time: (00:00 hrs, XX/XX/XX)Director: XXXXXXXXGeneral: XXXXXXXSupervisor: XXXXXXXXForeman: XXXXXXXXVehicle info: RC Unit #: XXXXOther Driver’s Name: XXXXXXXOther Driver’s Insurance info: XXXXXXOther Driver's Phone number: XXX-XXX-XXXXMake, Model and Tag number of any involved Vehicles: XXXXXXXXXWeather/Visibility: (conditions at time of incident)Type of Road: (Gravel, two lane highway, four lane interstate)

* Include any rules violations/ Ops Test Failures where relevant to the incident.

3

Incident Fact SheetTask Being Performed: (example: digging trench, installing house, etc.) Employees Present at Time of Incident: (List all employees present along with position. Ex: John Smith – Foreman)Rule Violation: (List RC rule violation if any apply)Description of Injury: (Doctor’s diagnosis as reported if any)Description of Incident: (What happened)

* Include any rules violations/ Ops Test Failures where relevant to the incident.

Photos for Illustration of Incident

3P (Process, People, Product) Analysis

Process:

People:

Product:

CAUSAL FACTORS CORRECTIVE ACTION

Product – Is there any evidence of defective equipment, appliances, or other physical contributing factor or environmental condition?

Process – Would adherence to applicable rules, processes, and operating practices in place have prevented the incident?

People – rule violations, failures, human factor behavioral exceptions

Corrective Actions – include timelines and responsible persons

Process:

People:

Product: