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Injury and Illness <br /> Prevention Program 2.22 <br /> Date Investigation Started (MM/DD/YYYY): <br /> Factors, Root Causes, and Solution (FRCS): Complete FRCS form and answer all 7 factor questions. If answering NO to <br /> Factors 1 —4 identify root cause(s) and explain why Qls) occurred. If answering YES to Factors 5—7 circle the root cause(s). <br /> Transfer the solutions guidance that addresses each root cause from the FRCS form to this form. Attach your completed <br /> FRCS Worksheet. If Factors 1-7 do not apply to the incident, write "External Cause" in the Factor column below and leave the <br /> remaining fields blank. <br /> DESCRIPTION OF UNDESIRABLE BEHAVIOR/CONDITION <br /> 1. <br /> 2. <br /> FACTOR(S)AND SOLUTION(S): HOW TO REDUCE POSSIBILITY OF INCIDENT RECURRING <br /> Selection of factors and solutions reflects the analysis of investigation team and is not meant to be a legally binding conclusion as to the Root Cause and/or <br /> solution. <br /> CAUSALFACTOR/ ROOT PERSON AGREED DUE ACTUAL <br /> BEHAVIOR/ CAUSE SOLUTION(S) RESPONSIBLE DATE COMPLETION <br /> CONDITION [Must Match Root Cause(s)] DATE <br /> INVESTIGATION TEAM: <br /> PRINT NAME JOB POSITION DATE SIGNATURE <br /> QUALITY REVIEW Correct root cause(s)identified? Do root cause(s)and solution(s)match?Are solution(s)feasible/maintainable? <br /> Name: Job Title: <br /> PART 4: Date Solutions were Implemented &Validated Were Solutions Effective? <br /> Date Solution Verifier/Validator Name and Job Title Details(of I&V performed) <br /> 1/2019 Corporate Health and Safety Management Program I ROUX <br />