Information

  • Site conducted

  • Document No.

  • Audit Title

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Personnel

Location Details

Location of Accident

  • Add location
  • Location Photo

  • Location of Accident in Location

About the Injured Person

Injured Person Details

  • Person Type

  • Name

  • Age

  • Date of Birth

  • Address

  • Job Title

  • Length of Time with Company

Training Records

  • Confirm Evidence of Training for employees

  • Induction Training

  • Manual Handling

  • Working at Heights / Access Equipment

  • Accident Reporting

  • Comments Regarding Training

About the Accident

Accident Details

  • Date of Accident

  • Accident Type

  • Potential for Harm

  • Accident Description

  • RIDDOR

  • Not RIDDOR reportable

  • RIDDOR ref

  • Date Repoted

  • Who Reported

  • Insurers Notified

  • You should notify your insurers of all serious accidents and incidents

  • Who Notified

  • When Notified

Investigation Notes

Investigation Information Gathering

  • How Did the adverse event happen

  • What activities where being carried out at the time?

  • Anything unusual or different about the working conditions?

  • We're there adequate safe working procedures and were they followed?

  • Nature and extent of injuries and ill health effects, if any.

  • If there was an injury, how did it occur and what caused it?

  • Was the risk know? If so, why wasn't it controlled?

  • Did the organisational arrangements of the work influence the adverse event?

  • Was maintenance and cleaning sufficient. Did it influence the adverse event?

  • We're the people involved competent and suitable?

  • Did the workplace layout influence the event?

  • Did the nature or shape of materials influence the adverse event?

  • Did difficulties using plant or equipment influence the adverse event?

  • Was safety equipment provided and was it adequate?

  • Did any other conditions influence the adverse event?

Photographic Record

Photographic Evidence

    Photo Evidence
  • Issue or Description

  • Photo

Risk Control Measures

Control Risk Measures

  • The following control measures are recomended.

  • Control Measure
  • Control Measure

Documentation Review

Documentation Review

  • The following documentation should be reviewed as a result of this adverse event

  • Safety Policy

  • Safety Arrnagements

  • Safety Responsibilities

  • Risk Assessments

  • Safe Operating Procedures

  • Training

  • Other documentation to be reviewed?

Risk Control Action Plan

Risk Control Actions

  • The following action plan should be carried out

  • Actions
  • Action or Control

  • To be completed by

Sign Off

Sign Off

  • This investigation was competed on the date and time stated and all areas of note where raised with the location management at the time of the report completion.

  • Add signature

Circulation

Report Circulation

  • This report should be circulated to the following groups and or people

  • Person Responsible for Health and Safety

  • Insurance Manager

  • Finance Director

  • HR Manager

  • Property Manager

  • Facilities Manager

  • Retail Manager

Circulation to Outside Agencies

  • HSE / EHO

  • Insurance Provider

  • Safety Advisor

Other Circulation

  • Tis report should also be circulated to the following groups

  • Other Circulation

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.