Information
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CONFIDENTIAL - for internal use only
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Incident Report No.
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Report Title
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Contract / Contract Number
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Client / Site
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Plant/Equipment
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Personnel/Operatives
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Contract Engineer
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Prepared by
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Conducted on
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Location
Details of Incident: Near Miss, Dangerous Occurence, Etc.
Details / Immediate Cause
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Date & Time of the Incident/Accident:
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Operators name:
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Location of Incident:
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Immediate cause of incident/accident: (consider all factors, including temperature, weather, system failure, design failure, equipment failure, poor housekeeping and the influence of alcohol or drugs)
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Root Cause
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Root cause of the incident/accident: (consider issues, such as lack of training & awareness, time constraints, communication and external influences)
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Additional Information
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Comments/Information:
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Remedial Action
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Action (s):
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Conclusion & Recommendations
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Conclusion & recommendations (analysis of evidence, comparison with standards, highlight the main issues, who is responsible, and so on):
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RIDDOR
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Does the incident/accident require reporting under RIDDOR?
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Yes.
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No.
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RIDDOR Details (F2508)
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Statements
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Witness Statement(s)
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Statement 1
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Statement 2
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Statement 3
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Statement 4
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Statement 5
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Statement 6
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Evidence / Information
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Evidence/Information
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Distribution
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Information recorded is based on initial investigation. This may be subject to change on verification of the facts.
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List:
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Report completed by:
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Select date
