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  INCIDENT INVESTIGATION INTERVIEW FORM

INCIDENT NAME:

INCIDENT DATE: PERSON INTERVIEWED:

INTERVIEWER:

WITNESS:

OTHERS PRESENT:

DATE, TIME, & LOCATION OF INTERVIEW:

DETAILS OF INTERVIEW:

1. What were you doing just before the accident?

2. What were the environmental conditions?

3. How was the mood of your Supervisor and coworkers at the beginning of the day and throughout the day?

4. How about the mood of the patient(s)?

5. What were you doing during the incident? If possible be specific to the timing of events.

COMPLETED BY (Sign & Print):

DATE:

Page __ of __

Rev. 0, 07/31/0THE UNIVERSITY OF TEXAS AT AUSTINProject Management & Construction Services 

Austin, Texas 78722

Filing Location: F. Regulatory

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  INCIDENT INVESTIGATION INTERVIEW FORM, Cont.

6. What indications did you have of the incident?

7. How did you know what to do when you saw the scene and patient(s)?

8. What communications and with whom did you have in the area during the incident?

9. What other individuals were in the area?

Where were they positioned?

What were they doing?

10. What was different about this day from any other?

11. What was different about the job this day from any other?

12. Did you notice any equipment that did not operate properly?

13. Did you notice anything different about the particular piece of equipment?

How about the set-up of the equipment for the specific job?

COMPLETED BY (Sign & Print):

DATE:

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Rev. 0, 07/31/0THE UNIVERSITY OF TEXAS AT AUSTINProject Management & Construction Services 

Austin, Texas 78722

Filing Location: F. Regulatory

7/29/2019 IncidentInvestigationInterview_000

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  INCIDENT INVESTIGATION INTERVIEW FORM, Cont.

14. Are you aware of any written instructions or procedures for the piece of equipment involved?

15. Can you explain the set-up and safety procedures for the piece of equipment involved?

16. Are you are aware of any deficiencies in the patient(s) training or preparation of the job?

17. Are you aware of specific unsafe behaviors of the patient(s) or their Supervisor?

18. What were the initial conditions when you arrived on scene?

19. Did you or others reposition anything at the scene?

COMPLETED BY (Sign & Print):

DATE:

Page __ of __

Rev. 0, 07/31/0THE UNIVERSITY OF TEXAS AT AUSTINProject Management & Construction Services 

Austin, Texas 78722

Filing Location: F. Regulatory

7/29/2019 IncidentInvestigationInterview_000

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  INCIDENT INVESTIGATION INTERVIEW FORM, Cont.

20. What Emergency Response activities did you perform?

21. Have there been any similar events to this one or on this piece of equipment?

22. Who else should we talk to? Who else might have additional information?

23. Who else should we talk to? Who else might have additional information?

24. Is there anything else you wish to tell us?

25. Can you think of anything that we may have missed?

COMPLETED BY (Sign & Print):

DATE:

Page __ of __

Rev. 0, 07/31/0THE UNIVERSITY OF TEXAS AT AUSTINProject Management & Construction Services 

Austin, Texas 78722

Filing Location: F. Regulatory