Accident & Incident Report Form - 2345

• Project:

  Select

• Accident/Incident Classification

  Select

• Details

• Description of event:

• Date and time of event:

  Date
• Location of event:
  Address

• Weather: (add screenshot of sensors or weather app)

• Lead Investigator:

• Additional/Supporting Investigators:

• Distribution of Accident/Incident Report Form

Summary & Causation

• Executive Summary:

• Immediate Actions Taken:

• Key Findings:

• Immediate Cause:

• Contributing Factors:

• Route Cause:

• Photographic evidence:

  Media

Prevention of Reoccurrence & Knowledge Sharing

• List actions to be taken to prevent reoccurrence: (issue internal observations as an 'action' and assign accordingly)

• List other observations which require action: (not related to the event but requiring management action)

• Does the event offer learning opportunities for the wider organisation?

  Yes

  No

  N/A
Companies/Parties Involved

• undefined

• Were personnel injured as a result of the event?

  Yes

  No

  N/A
Injured Party (IP)

• Name of IP:

• Job Role:

• Supervisor

• Address:

• Telephone Number:

• Notes/Additional Info

Medical Treatment & Absence

• Injury Diagnosis

  Select

• Mechanism of Injury

  Select

• Injury Location

  Select

• Medical Treatment

  Select

• Absence from Work

  Select

• Description of injury

• Is the injury notifiable to the HSE (RIDDOR 2013)?

  Yes

  No

  N/A
Witness

• Name of witness:

• Job Role:

• Employer:

• Address:

• Telephone Number:

• Witness Statement

  Media

Supporting Evidence

• Evidence Type

• Photographs/Video/Evidence

  Media

Investigator Details

• Name

  Sign

• Position:

• Telephone Number:

• Date:

  Date