Accident / Incident Initial Investigation Report

• Site conducted

  Select

• Conducted on

  Date

• Prepared by

• Accident Report Number

• Name of injured person(s)

• Date of accident/incident

  Date

• Length of absence from work due to accident (If known)

  Yes

  No

  N/A

• Incident / near miss

  Yes

  No

  N/A

• Undesirable conditions

  Yes

  No

  N/A

• Damage only

  Yes

  No

  N/A

• Accident

  Yes

  No

  N/A

• Ill health

  Yes

  No

  N/A

• Minor Injury

  Yes

  No

  N/A

• Serious Injury

  Yes

  No

  N/A

• Major Injury

  Yes

  No

  N/A

• Death

  Yes

  No

  N/A

Details of the incident or accident

• What was the injured person actually doing at the time of the accident/incident?

• How did the injury/damage occur and what caused it?

• Describe the injuries/damage caused and any outstanding problems?

• What emergency measures were taken?

• Names of any witnesses

• Name of supervisor of the area where the accident/incident occurred

• Detail any equipment involved in the accident/incident. Name of equipment, model no, serial no

• Detail any problems or anything different about the working conditions where the accident/incident occurred?

• Were adequate safe working procedures in place? Yes (review to follow)

• What PPE was being worn by the person injured/present at the time of the accident/incident?

• Was the injured/affected person sufficiently competent? Detail any training provided

• What immediate measures were put into place following the accident to ensure the area was safe?

Recommendations

• Detail recommendations to reduce risks or remove hazard

• Further investigation required?

  Yes

  No

  N/A

• Signed by

  Sign