Title Page
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Conducted on
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Prepared by
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Principal Contractor details and contact number
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Contractor involved
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Site Manager or person in charge
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Client name and contact number
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Site Location
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Exact location of accident/incident
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Brief details of incident (When, Where, Who & Why) no more than 6 lines
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Number of injured persons?
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Number of witnesses?
Type of Accident / Incident
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Fatality?
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Major Injury?
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Dangerous Occurrence?
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Minor injury exceeding 7 days away from work (RIDDOR Reportable)?
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Minor injury not exceeding 7 days away from work?
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Damage to organisations property / equipment
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Incident involving a member of the public
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Near Miss?
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Service strike
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Environmental Incident?
Details of injured persons and / or witnesses
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Person 1
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Name:
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Address:
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Age: (D.O.B.)
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Contact number:
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Induction number (if issued):
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Date of induction:
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Trade / occupation:
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Employment status ( direct - Subcontractor - self-employed etc.)
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Injury(s) sustained (provide as much detail as possible):
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Hospital attended (or other i.e. doctor - medical centre)
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Likelihood of returning to work (when?)
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Employer / Agency / Self-Employed (insert details)
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Is this person ?
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The injured party?
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Witnessed the incident?
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Witnessed events before and/or after?
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Management on site?
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Other?
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Include events described by witness / injured party
Person 2 details
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Name:
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Address:
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Age: (D.O.B.)
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Contact Number:
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Induction number (if issued)
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Date of induction:
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Trade / Occupation:
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Employment status ( direct - Subcontractor - self-employed etc.)
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Injury(s) sustained (provide as much detail as possible):
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Hospital attended (or other i.e. doctor - medical centre)
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Employer / Agency / Self-Employed (insert details)
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Is this person?
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The injured party?
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Witnessed the incident?
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Witnessed events before and/or after?
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Management on site?
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Other?
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Include events described by witness / injured party
Person 3
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Name:
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Address:
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Age: (D.O.B.)
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Contact number?
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Induction number (if issued)
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Date of induction:
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Trade / Occupation:
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Employment status ( direct - Subcontractor - self-employed etc.)
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Injury(s) sustained (provide as much detail as possible):
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Hospital attended (or other i.e. doctor - medical centre)
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Employer / Agency / Self-Employed (insert details)
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Is this person?
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The injured party?
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Witnessed the incident?
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Witnessed events before and/or after?
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Management on site?
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Other?
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Include events described by witness / injured party
Companies involved - Repeat sections where more than one company are involved.
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Company 1 details:
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Company name:
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Address and telephone number
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Role:
Company 2 details
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Company name:
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Address and telephone number:
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Role:
Company 3 details:
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Company name:
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Address and telephone number:
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Role:
Details of Plant / Equipment involved. Repeat sections where more plant or equipment was involved.
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Was there plant or equipment involved with the incident?
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Type of plant / equipment
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Owner of plant / equipment (hire company or direct)
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Owners contact details
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Registration number / serial number (or other identification)
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If hired, by whom?
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Operator (driver/user)?
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Details of operators cert of competence.
Plant / equipment (item2)
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Type of plant / equipment
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Owner of plant / equipment (hire company or direct)
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Owners contact details
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Registration number / serial number (or other identification)
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If hired, by whom?
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Operator details (driver/user)?
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Details of operators cert of competence
Plant / equipment (item 3)
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Type of plant / equipment
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Owner of plant / equipment (hire company or direct)
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Owners contact details
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Registration number / serial number (or other identification)
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If hire, by whom?
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Operator details (driver/user)
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Details of operators cert of competence
Detailed information about the accident / incident
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Describe fully how the incident occurred - include events leading up to the accident. Describe fully what happened post-accident to include initial actions taken to prevent a reoccurrence and making the area safe?<br>
Investigators comments
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Investigator - Comments / observations / recommendations Immediate steps taken to prevent a re-occurrence.<br>
Accident investigation - Evidence gathering guidance
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This check list is to be used as a guidance on the evidence required to fully complete an investigation where court action may be taken. Must include as much evidence as possible in line with the guidance.
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Evidence of site inductions
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Copies of any RAMS signed by operatives
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Any relevant Toolbox Talks (pre and post incident)
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Permits relevant to the works and any service drawings
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Lift plans (where applicable)
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Plant / accessories 6/12 monthly thorough examination certificates and daily checks sheets.
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Certificates of competence - CPSC/CSCS/NRSWA etc. (both sides)
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Statements from injured party(s) and witnesses
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Images taken by all person such as site manager, supervisor, operatives and investigator.
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Video not more than 20 seconds if taken.
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Fully completed investigation reports by the PC and Client.
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Has the following information been provided for service strikes?
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Name of supervisor
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Copies of permit to dig and service drawings
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CAT/Genny - operators competence - serial No - Date of calibration for both.
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Evidence of service locations (images of spray paint areas)
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Sand / Marker tape present - Image of service depth.
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Images of services present with area of strike.
