Title Page
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Project:
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Date and time of event:
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Lead Investigator:
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Additional/Supporting Investigators:
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Description of event:
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Distribution:
Summary & Causation
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Executive Summary:
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Key Findings:
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Immediate Cause:
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Contributing Factors:
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Route Cause:
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Mechanism of Injury
- Struck by Moving Object
- Struck Against
- Struck by Moving Vehicle
- Contact with Machinery
- Fire/Explosion
- Fall from Height
- Slips, Trips and Falls on the Same Level
- Non-Work Related
- Exposure to Harmful Substances
- Lifting and Handling Injuries
- Contact with Electricity
- Workplace Violence
- Trapped by Something Collapsing/Overturning
- Injured by an Animal
- Drowning/Asphyxiation
- Other
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Accident/Incident Class
- Minor Accident
- Major Accident (RIDDOR)
- Minor Incident
- Major Incident
- Dangerous Occurrence (RIDDOR)
- Near Miss
- Accident - Specified Injury (RIDDOR)
- Incapacitation (Over 7 Days - RIDDOR)
- Fatality (RIDDOR)
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Photographic evidence:
Medical Care & Lost Time
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Medical Care
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Injury Location
- Head
- Face
- Neck
- Shoulders
- Torso
- Groin
- Legs
- Arms
- Back
- Feet
- Hands
- Fingers
- Toes
- Others
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Injury Diagnosis
- Fracture
- Amputation
- Crush Injury
- Loss of Sight
- Burn/Scalding
- Scalping
- Loss of Consciousness or Asphyxia
- Heat Stroke
- Minor Laceration/Graze
- Major Laceration/Cut
- Puncture
- Hypothermia
- Other
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Lost Time
- No lost time
- 1 Day
- 2 Days
- 3 Days
- 4 Days
- 5 Days
- 6 Days
- 7 Days
- Other
Prevention of Reoccurrence & Knowledge Sharing
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List actions to be taken to prevent reoccurrence:
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List other observations which require action:
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Does the event offer learning opportunities for the wider organisation?
Key Personnel
- Injured Party (IP)
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Were personnel injured as a result of the event?
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Name of IP:
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Job Role:
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Address:
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Telephone Number:
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Description of injury
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Severity
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Mechanism of injury
Medical Treatment & Absence
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Medical Treatment
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Accident Classification
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Absence from Work
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Is the injury notifiable to the HSE (RIDDOR 2013)?
Witness
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Name of witness:
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Job Role:
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Employer:
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Address:
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Telephone Number:
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Witness Statement
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Witness Signature
Supporting Evidence
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Key personnel statements taken and attached?
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List evidence provided:
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Where are copies of evidence retained?
Investigator Details
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Name:
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Position:
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Telephone Number:
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Date:
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Signed:
