Accident/Incident & Investigation report

• Audit Title

• Document No.

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Site details

• Site that employee was working at;

• Name of Principal contractor

  Select Mace COMO Overbury ISG BWI RI Works 33 London

  • Mace
  • COMO
  • Overbury
  • ISG
  • BWI
  • RI Works
  • 33 London

• Name of Principal contractor if not listed above

  Yes

  No

  N/A

• Employers details

Accident/Incident Details

• Date and time of injury;

  Date

• Employee Name

• Relevant Training / Toolbox talk to the task being undertaken

• Job Title:

  Select Labourer Ganger Supervisor Brick Layer Forklift driver Banksman Slinger Manager Hoist operator Welfare Plumber Painter Fitter Fixer Plant operator Electrician Apprentice

  • Labourer
  • Ganger
  • Supervisor
  • Brick Layer
  • Forklift driver
  • Banksman
  • Slinger
  • Manager
  • Hoist operator
  • Welfare
  • Plumber
  • Painter
  • Fitter
  • Fixer
  • Plant operator
  • Electrician
  • Apprentice

• Job title if not listed above

• Location of accident (please be specific)

• Nature of Incident or Injury

• Describe who, what, when,where, why and how injury occurred:

• Contributing causes of the Incident: (Inadequate training, Inadequate supervision. Employee not following proper safety procedures and instructions)

• Possible Cause or Causes of the incident: (Inadequate PPE, Not Paying attention to surroundings, failure to utilise safety equipment)

• What is the employee's current status if injured: Describe. ( Returned to work the next day, off of work do to injury, off of work do to restrictions, In hospital, etc.)

• Severity:

  Select First Aid Repotable Lost Time Restricted Duty Fatality

  • First Aid
  • Repotable
  • Lost Time
  • Restricted Duty
  • Fatality

Time line for the accident

• Set out the time line for the incident

Supervision details

• Was a DAB, Take 5 or Risk Assessment completed before work began:

  Yes

  No

  N/A

• HSE Informed?

  Yes

  No

  N/A

• Client (PC) Informed?

  Yes

  No

  N/A

• Date and Time when the employer was notified:

  Date

• Do we have Light duty work for him based on restrictions?

  Yes

  No

  N/A

Injured Party statement

• undefined

• Name & Signature of the injured party

  Sign

Witness statements

• Witnesses 1

• Name and signature of the witness 1

  Sign

• Witnesses 2

• Name and signature of the witness 2

  Sign

• Witnesses 3

• Name and signature of the witness 3

  Sign

Injury Details if Applicable

• Where was the Medical treatment first provided?

  Select Minor Onsite A&E Treated/Released Hospitalized > 24 hrs Hospitalized < 24hrs No Medical Treatment

  • Minor Onsite
  • A&E Treated/Released
  • Hospitalized > 24 hrs
  • Hospitalized < 24hrs
  • No Medical Treatment

• What type of provider performed treatment?

  GP

  A&E Hospital

  On-Site First Aid

• If you choose other please specify.

• Provider Doctor Details

• Part of Body injured:

• Will the employee have any restrictions:

  No

  Yes

• If so, what are they?

• Anyone else injured:

  Yes

  No

  N/A

Corrective Actions

Action: Short Term

• What was the immediate action taken to correct the issue (how was this done):

• Who was the responsible party for correcting the issue:

Action: Long Term

• What is the long term action needed to correct the issue:

• Who was the responsible party for correcting the issue:

Additional Information

• Lessons Learned:

• Please provide all attachments that apply: Pictures, Drawings, Training Records, Statement of Employee, Statement of Witness/es, Other.

  Yes

  No

  N/A

Investigation Conclusions

• undefined

Person Completing Form (please sign below)

• Is the above report a true reflection of the Accident / Incident

  Sign

Supervisor in Charge (please sign below)

• Is the above report a true reflection of the Accident / Incident

  Sign

Injured Party witnessing the completion of the forms agreement with the content and that it is a true reflection of the accident / Incident

• Is the above report a true reflection of the Accident / Incident

  Sign