Incident Capture Form

Corrective action

Near miss

Accident / injury

Improvement project

Initiator details

Date *

Initiator *

CAR number

Requirement reference

Source of corrective action request *

Description of the deficiency *

Investigator section

Interim correction / containment actions

Analysis of causes (5 Whys)

W1

W2

W3

W4

W5 (root cause)

Proposed actions to address root cause(s)

#	Action description	Target date
1
2
3

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Reviewer / approver

Review risk assessment

Review similar processes

Review similar products

Approver initials

Implementer & verifier

Evidence of implementation attached?

Yes No

Evidence of effectiveness attached?

Yes No

Actions implemented as planned and on-time?

Yes No

Deficiency resolved permanently?

Yes No

Verifier comments

Effectiveness validation comments

Closure

CAR closed by

Date closed

Escalation (2nd stage CAR#)

Issued to

Near miss details

Project *

Date of report *

Time

Name of person reporting *

Reported to

Near miss related to *

Health & safety Quality

Precise location *

Description of near miss *

Employer information

Employer

Supervisor

Telephone

Fax

Address

City

Province

Postal code

Injured employee

Name *

Age

Telephone

Fax

Occupation

Address

City

Province

Postal code

Experience at work involved

Nature of injury *

Witnesses

Witness A

Name

Employer

Occupation

Telephone

Address

City

Province

Postal code

Witness B

Name

Employer

Occupation

Telephone

Address

City

Province

Postal code

Witness C

Name

Employer

Occupation

Telephone

Address

City

Province

Postal code

Accident details & care

Accident date *

Accident time

Project

Location of accident

Address

City

Province

Explain what happened (what, where, when, who, how) *

Immediate cause

Underlying cause

How can the accident be prevented?

Actions taken to prevent recurrence

Treatment & care provided

Action by

Report by

Reporting log

Reported to	Name	Date	Time	Telephone	Notes
Supervisor
Ministry of Labour
Head office

Injury treatment record

Project

Supervisor

Injured person	Injury details	Injury date/time	Treatment given	Treatment date/time	Treated by	Witness name

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Project definition & clarification

Project name *

Project leader

Customer

Sponsor

Start date

Target closure date

Team members

Project definition / clarification (PFDs, cause & effect diagrams)

Root cause analysis

Most probable causes

Real (confirmed) causes

Solution plan

#	Action	Timing	Responsible	% Complete	Comments
1
2
3

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