Accident/ Incident investigation Form v2

• Site conducted

  Select

• Conducted on

  Date

• Prepared by

• Location
  Address

• The manager/supervisor/or a member of the H&S team of the injured person must complete this form as soon as possible after the incident

• Name:

• Worker ID

• Speaks English?:

  Yes

  No

• Employed as (occupation):

• Line Manager:

• Department:

• Has a accident incident report form been completed?

  Yes

  No

• why was this not completed?

• if yes then attached accident form

• if no then explain why this wasn't done.

Describe the Incident

• Site:

• Location:

• Date and Time:

  Date

• Has the person returned to work?

  Yes

  No

• Do they have doctors note?

  Yes

  No

• Were they using machinery?

  YES

  NO

  Other

• What machinery was being used:

• What tools were being used?

• brief description

• what happened?

• Part of Body affected

• Photos of Injury

  Media

• Nature of Injury

  Select Abrasion/graze/scrape Amputation bee sting broken bone bruise burn - heat burn - chemical crushed cut puncture sprain/strain swelling puncture other

  • Abrasion/graze/scrape
  • Amputation
  • bee sting
  • broken bone
  • bruise
  • burn - heat
  • burn - chemical
  • crushed
  • cut puncture
  • sprain/strain
  • swelling
  • puncture
  • other

• Please input the "other"

PPE

• Was PPE worn ?

  Yes

  No

• why was PPE not worn

• select what PPE was worn

  Select Gloves/Gauntlets Goggles/Glasses Face Shield Overalls/aprons Safety Boots High visibility clothing Ear protection Respirator Face Mask

  • Gloves/Gauntlets
  • Goggles/Glasses
  • Face Shield
  • Overalls/aprons
  • Safety Boots
  • High visibility clothing
  • Ear protection
  • Respirator
  • Face Mask

• Is PPE in good condition?

  Yes

  No

• What actions/ suggestions have been given to prevent this from happening again.

• Outcome of the Investigation

• Reviewed by H&S:

  Yes

  No

• Add signature

  Sign