The Incident Investigation Form is a critical document used in Dutch workplaces to ensure thorough and compliant investigation of workplace incidents, accidents, and near-misses. It is designed to meet the requirements of the Dutch Working Conditions Act (Arbeidsomstandighedenwet) and related regulations, while also incorporating GDPR considerations for personal data protection. This form should be used whenever an incident occurs that affects workplace safety, employee health, property, or environmental conditions. It captures essential information about the incident, involved parties, root causes, and corrective actions, serving both as a legal record and a tool for preventing future occurrences. The document supports regulatory compliance, insurance claims, and organizational learning, while providing a standardized approach to incident investigation across different departments and incident types.
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1. Incident Identification: Basic information including incident ID, date, time, and location
2. Initial Report Details: Who reported the incident, when it was reported, and immediate actions taken
3. Incident Description: Detailed narrative of what happened, including sequence of events
4. Persons Involved: Details of all people involved, including witnesses (with GDPR compliance notice)
5. Impact Assessment: Evaluation of harm or damage to people, property, environment, or operations
6. Investigation Process: Methods used, evidence collected, and interviews conducted
7. Root Cause Analysis: Identification and analysis of direct and underlying causes
8. Immediate Actions Taken: Description of emergency response and immediate containment measures
9. Preventive Measures: Recommended actions to prevent recurrence
10. Sign-off and Verification: Approval sections for investigator, supervisor, and safety officer
1. Environmental Impact: Required when incident involves environmental releases or damage
2. Equipment/Machinery Details: Required when incident involves equipment failure or malfunction
3. Third Party Involvement: Required when contractors or external parties are involved
4. Medical Response Details: Required for incidents involving injuries or health issues
5. Cost Impact Analysis: Optional section for calculating direct and indirect costs
6. Regulatory Reporting: Required when incident meets statutory reporting thresholds
7. Union Representative Statement: Required when incident involves union members or collective agreement provisions
1. Witness Statements: Collected statements from witnesses (with GDPR notices)
2. Photographic Evidence: Photos, videos, or visual documentation of the incident scene
3. Technical Reports: Any relevant technical analyses or expert assessments
4. Risk Assessment Matrix: Standard risk assessment tool for evaluating incident severity and likelihood
5. Investigation Timeline: Detailed chronological reconstruction of events
6. Training Records: Relevant training and certification records of involved parties
7. Equipment Maintenance Records: If applicable, maintenance history of involved equipment
8. Incident Scene Diagrams: Sketches or diagrams showing incident location and relevant details
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