Environmental Incident and Corrective Action Report Form

Part A: To be completed by the person reporting the incident

Description of incident

Actual/potential impact?

Immediate action response taken

What do you think could have been done to prevent this incident from occurring?

Any other comments or observations?

Witness details (if applicable)

Supervisor/s sign-off

Part B: Investigation checklist

What factors caused the incident (e.g. management, the work environment, equipment, maintenance, individual)?

What do you think could have been done to prevent this incident from occurring?

Any other comments or observations?

Part C: Corrective action report

Corrective action

Root cause and preventative action to be taken to reduce the risk of the incident happening again

Part D: Approved actions

Verification that corrective actions have been completed/implemented and are effective