Title Page
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Project:
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Accident/Incident Classification
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Details
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Description of event:
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Date and time of event:
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Location of event:
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Weather: (add screenshot of sensors or weather app)
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Lead Investigator:
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Additional/Supporting Investigators:
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Distribution of Accident/Incident Report Form
Summary & Causation
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Executive Summary:
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Immediate Actions Taken:
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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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Photographic evidence:
Prevention of Reoccurrence & Knowledge Sharing
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List actions to be taken to prevent reoccurrence: (issue internal observations as an 'action' and assign accordingly)
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List other observations which require action: (not related to the event but requiring management action)
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Does the event offer learning opportunities for the wider organisation?
Companies/Parties Involved
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Key Personnel
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Were personnel injured as a result of the event?
Injured Party (IP)
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Name of IP:
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Job Role:
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Supervisor
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Address:
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Telephone Number:
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Notes/Additional Info
Medical Treatment & Absence
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Injury Diagnosis
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Mechanism of Injury
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Injury Location
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Medical Treatment
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Absence from Work
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Description of injury
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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
Evidence
- Supporting Evidence
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Evidence Type
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Photographs/Video/Evidence
Investigator Details
Investigator Details
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Name
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Position:
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Telephone Number:
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Date: