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Incident Investigation Form

Incident Investigation Form Template for Netherlands

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Key Requirements PROMPT example:

Incident Investigation Form

"I need an Incident Investigation Form for our chemical manufacturing facility in Rotterdam that complies with BRZO regulations and includes detailed sections for environmental impact assessment and hazardous materials handling, with extra emphasis on root cause analysis templates."

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Document background
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.
Suggested Sections

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

Optional Sections

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

Suggested Schedules

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

Authors

Alex Denne

Head of Growth (Open Source Law) @ Genie AI | 3 x UCL-Certified in Contract Law & Drafting | 4+ Years Managing 1M+ Legal Documents | Serial Founder & Legal AI Author

Linkedin in social icon imageX social icon image
alex.den.21@genieai.co
Relevant legal definitions
Incident
Accident
Near Miss
Major Accident
Root Cause
Contributing Factor
Affected Party
Investigating Officer
Immediate Action
Corrective Action
Preventive Action
Personal Data
Material Damage
Hazard
Risk
Control Measure
Safe System of Work
Competent Person
Direct Cause
Underlying Cause
Severity Level
Lost Time Incident
Reportable Incident
Environmental Impact
Witness Statement
Physical Evidence
Investigation Team
Safety Critical Equipment
Emergency Response
Risk Assessment
Personal Protective Equipment (PPE)
Dangerous Occurrence
Work-Related Illness
Occupational Disease
Safety Representative
Contractor
Regulatory Authority
Workplace
Technical Expert
Documentation
Relevant Industries

Manufacturing

Construction

Healthcare

Transportation and Logistics

Chemical Industry

Energy and Utilities

Mining and Raw Materials

Food and Beverage

Retail

Warehousing

Agriculture

Education

Professional Services

Information Technology

Hospitality

Pharmaceutical

Automotive

Maritime

Relevant Teams

Health and Safety

Operations

Human Resources

Quality Assurance

Risk Management

Environmental Compliance

Security

Emergency Response

Maintenance

Production

Legal

Facility Management

Employee Relations

Training and Development

Relevant Roles

Health and Safety Manager

Operations Manager

Facility Manager

Production Supervisor

Quality Control Manager

Risk Manager

Environmental Compliance Officer

Human Resources Director

Department Supervisor

Safety Coordinator

Plant Manager

Site Director

Maintenance Manager

Security Manager

Compliance Officer

Emergency Response Coordinator

HSE Specialist

Quality Assurance Manager

Industries
Working Conditions Act (Arbeidsomstandighedenwet): Primary Dutch legislation governing workplace safety and health. Requires employers to record and investigate workplace incidents and accidents.
GDPR (AVG - Algemene verordening gegevensbescherming): European data protection regulation implemented in Dutch law, governing the collection and processing of personal data in incident reports.
Dutch Civil Code (Burgerlijk Wetboek): Contains provisions regarding employer liability and duty of care, relevant for incident investigations and follow-up actions.
Environmental Management Act (Wet Milieubeheer): Requires reporting and investigation of environmental incidents and their impact.
Major Accidents (Risks) Decree (Besluit risico's zware ongevallen - BRZO): Specific requirements for investigation and reporting of major industrial accidents in high-risk facilities.
Working Conditions Decree (Arbeidsomstandighedenbesluit): Detailed regulations on workplace incident reporting, investigation procedures, and documentation requirements.
Works Councils Act (Wet op de ondernemingsraden): Governs employee representation rights in workplace investigations and safety matters.
Teams

Employer, Employee, Start Date, Job Title, Department, Location, Probationary Period, Notice Period, Salary, Overtime, Vacation Pay, Statutory Holidays, Benefits, Bonus, Expenses, Working Hours, Rest Breaks,  Leaves of Absence, Confidentiality, Intellectual Property, Non-Solicitation, Non-Competition, Code of Conduct, Termination,  Severance Pay, Governing Law, Entire Agreemen

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