Investigation Performed By: (your name here) Regarding: (date of incident - Subdivision – Type of Accident/Incident/Injury) report prepared: (date)

2 Incident Fact Sheet Project: XXXXXXX Division: XXXXXXXX Subdivision: XXXXXXXXX Physical Location: (near city, state) Actual location of Incident: (example: CP Midland, MP 234.9, County Road 25) Date & Time: (00:00 hrs, XX/XX/XX) Director: XXXXXXXX General: XXXXXXX Supervisor: XXXXXXXX Foreman: XXXXXXXX Vehicle info: RC Unit #: XXXX Other Driver’s Name: XXXXXXX Other Driver’s Insurance info: XXXXXX Other Driver's Phone number: XXX-XXX-XXXX Make, Model and Tag number of any involved Vehicles: XXXXXXXXX Weather/Visibility: (conditions at time of incident) Type of Road: (Gravel, two lane highway, four lane interstate) * Include any rules violations/ Ops Test Failures where relevant to the incident.

3 Incident Fact Sheet Task Being Performed: (example: digging trench, installing house, etc.) Employees Present at Time of Incident: (List all employees present along with position. Ex: John Smith – Foreman) Rule Violation: (List RC rule violation if any apply) Description of Injury: (Doctor’s diagnosis as reported if any) Description of Incident: (What happened) * Include any rules violations/ Ops Test Failures where relevant to the incident.

Photos for Illustration of Incident

3P (Process, People, Product) Analysis Process: People: Product: CAUSAL FACTORS CORRECTIVE ACTION Product – Is there any evidence of defective equipment, appliances, or other physical contributing factor or environmental condition? Process – Would adherence to applicable rules, processes, and operating practices in place have prevented the incident? People – rule violations, failures, human factor behavioral exceptions Corrective Actions – include timelines and responsible persons Process: People: Product: