Accident / Incident Investigation Report Form

• No

• Site conducted

  Select

• Conducted on

  Date

• Prepared by

• Accident Book Reference No:

• Name of Injured Person:

• Are they an Employee Contractor Visitor Other

  EmployeeEmployee

  Contractor

  Visitor

  Other

• Your reason on-site

• Location where the Accident / Incident Occurred

• Date & Time of Accident / Incident (24 hour clock)

  Date

• Did the Accident / Incident require reporting to the authorities (RIDDOR)?

  Yes

  No

  N/A

• When was the Accident / Incident reported to the authorities?

• Were there any witnesses to the Accident / Incident?

  Yes

  No

  N/A

• Name's

• Details of witnesses (names, addresses and contact telephone numbers etc.)

• Have the witnesses provided statements?

  Yes

  No

  N/A

• Were there any photographs taken?

  Yes

  No

  N/A

Details of The Accident or Incident

• Description of Accident or Incident (as much detail as possible of events leading up to the Accident / Incident with details of the circumstances immediately prior to the event and details of working conditions – for example weather, visibility, temperature, housekeeping standards, unusual working conditions etc. and any other factors which may be considered as being influential leading up to the situation)

• Were there any injuries sustained:

• Nature of Injury (e.g. fracture, crush, laceration, bruising etc.)

• Location of Injury (e.g. arm, hand, body, head, leg, foot etc.)

• Was First Aid treatment administered and if so what treatment:

  Yes

  No

  N/A

• Name(s) of First Aider / Emergency First Aider / Appointed Person:

• Did the injured person lose consciousness?

  Yes

  No

  N/A

• Was the injured person taken to hospital? (if so please give details)

  Yes

  No

  N/A

• Was the injured person admitted to hospital? (if so please give details)

  Yes

  No

  N/A

• Did the injured person refuse to go to hospital? (if so please give details)

  Yes

  No

  N/A

• Is the injury likely to result in the person being absent from work? (if so please give details)

  Yes

  No

  N/A

• Details

• Briefly describe what the injured person was actually doing at the time of the accident or explain the circumstances leading up to the incident:

• Was the person authorised to be in the area where the accident / incident occurred?

  Yes

  No

  N/A

• How long had the injured person or the person involved in the incident been carrying out this activity? (describe the person’s experience in doing this activity)

• Was the person involved trained in regard to this activity? (if YES please provide details of training provisions – full training records should be made available for examination):

  Yes

  No

  N/A

• Training

  Media

• Does the person appear to have acted in an unsafe manner? (if YES please give details):

  Yes

  No

  N/A

• Details

• Detail any risk assessments undertaken for the activity involved in the Accident/Incident: (include persons who completed the assessments, Ref Nos., dates of assessment and any reviews, appropriate control measures required etc. – copies of relevant risk assessments should retained with this form and made available for future examination)

  Media

• How have the risk assessments been communicated to the workforce?: (If so how and when)

• Was there a safety procedure developed as a result of the risk assessments? (if YES please give details of documented safe systems of work or instructions given):

  Yes

  No

  N/A

• Was the procedure / safe system of work being followed prior to the Accident / Incident?

  Yes

  No

  N/A

• Environment – Were there any environmental conditions that may have had a bearing on the accident or incident? (e.g. adverse weather, wind, sunlight, rain, poor lighting and wet floor etc.):

• Was any protective clothing / equipment required, was it available and was it in use?

  Yes

  No

  N/A

• (please give details):

• Was any equipment or machinery involved in the Accident / Incident? (please provide details of equipment or machinery, any part of equipment or machinery causing injury, was the equipment or machinery in motion and were there any apparent faults found with the equipment or machinery or its guarding, and where applicable had planned guard checks been carried out?):

• Were any safety devices required, were they available and in use? (please give details)

  Yes

  No

  N/A

• details

• Were any hazardous substances involved in the accident or incident? (if Yes please give details):

  Yes

  No

  N/A

• details

• Detail what Supervision was in place at the time of the accident or incident:

• Provide sketches / diagrams to explain the above event(s) (please attach to this form)

  Media

• What in your opinion do you consider were the actual and probable causes of the accident or incident? (Brief overview)

• Detail any remedial action taken immediately after the accident / incident or required to prevent re-occurrence:

• Have the actions identified been implemented? (if not when will the actions be implemented?)

  Yes

  No

  N/A

• details

  Yes

  No

  N/A

• Name of person carrying out this investigation:

• Signed: Date:

  Sign

• Name of Senior Manager:

• Signed: Date:

  Date

• All additional information, statements, photographs and RIDDOR Report etc. should be attached to the rear of this document as appendices and retained in a secure location to comply with data protection legislation

Accident / Incident Investigation Conclusion

• The following are suggested common causes of Accident / Incidents and may be used as a reference to determine as part of the investigation what the Immediate, Underlying and Root causes to an event were

Causative Factors

• Causative Factors

• IMMEDIATE CAUSES

• UNDERLYING CAUSES

• ROOT CAUSES

• Action(s) identified through the investigation process required in order to prevent a re-occurrence of the accident / incident

Actions to be compleated

• Action / Control Measure

• Responsible Person

• Date for Copletion

  Date

• Date of Completion

  Date

• Close off Signature

  Sign