Title Page

  • Project:

  • Accident/Incident Classification

  • Details

  • Description of event:

  • Date and time of event:

  • Location of event:
  • 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:

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?

  • Companies/Parties Involved
  • undefined

Key Personnel

  • Were personnel injured as a result of the event?

  • Injured Party (IP)
  • Name of IP:

  • Job Role:

  • Supervisor

  • Address:

  • Telephone Number:

  • Notes/Additional Info

Medical Treatment & Absence

  • Injury Diagnosis

  • Mechanism of Injury

  • Injury Location

  • Medical Treatment

  • Absence from Work

  • Description of injury

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

  • Witness
  • Name of witness:

  • Job Role:

  • Employer:

  • Address:

  • Telephone Number:

  • Witness Statement

Evidence

    Supporting Evidence
  • Evidence Type

  • Photographs/Video/Evidence

Investigator Details

Investigator Details

  • Name

  • Position:

  • Telephone Number:

  • Date:

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.