Accident Investigation Report

• Site

  Select Cadeby Telford Ellistown Littleport Lydney Alnwick Grantham Weston Underwood Drakelow Byley

  • Cadeby
  • Telford
  • Ellistown
  • Littleport
  • Lydney
  • Alnwick
  • Grantham
  • Weston Underwood
  • Drakelow
  • Byley

• Accident reference No.

• Conducted on

  Date

• Prepared by

• Location
  Address

Accident Investigation Report:

• Accident Report Number:

• Company Accident report attached?

  Yes

  No

  N/A

• Has the HSE been Notified?

  Yes

  No

  N/A

• RIDDOR Report added?

  Yes

  No

  N/A

• Accident Date & Time:

  Date

Company Information

• Name:

• Address:
  Address

Employee Information:

• Name:

• Home Address:
  Address

• Age:

• Sex:

• Department:

• Job Title:

• Employee Status:

  Select Full Time Part Time Temporary Contractor Other

  • Full Time
  • Part Time
  • Temporary
  • Contractor
  • Other

• Length of Employment:

  Select Less Than 1 Month 1 - 5 Months 6 Months to 5 Years More Than 5 Years More than 20 Years

  • Less Than 1 Month
  • 1 - 5 Months
  • 6 Months to 5 Years
  • More Than 5 Years
  • More than 20 Years

• Time in Occupation at time of accident:

  Select Less Than 1 Month 1 - 5 Months 6 Months to 5 Years More Than 5 Years More than 20 Years

  • Less Than 1 Month
  • 1 - 5 Months
  • 6 Months to 5 Years
  • More Than 5 Years
  • More than 20 Years

Injury Information:

• Date & Time Reported:

  Date

• Nature of Injury and Part of Body Affected:

• Employees Specific Task and Activity at the Time of Accident:

• Was the Employee Working:

  Select Working Alone Working with assigned group Supervised Not Supervised

  • Working Alone
  • Working with assigned group
  • Supervised
  • Not Supervised

• Severity of Injury:

  Select Fatality Major Over 7 Day Over 3 Day First Aid

  • Fatality
  • Major
  • Over 7 Day
  • Over 3 Day
  • First Aid

• Name and Address of Hospital

Witnesses:

• Name

• Statement

  Yes

  No

  N/A

• Name

• Statement Added?

  Yes

  No

  N/A

• Name

• Statement

  Yes

  No

  N/A

• Name

• Statement Added

  Yes

  No

  N/A

• Name

• Statement Added

  Yes

  No

  N/A

• Name

• Statement Added

  Yes

  No

  N/A

Scene of Accident Information:

• Specific Location:
  Address

• Describe How the Accident Occurred:

• Diagram any Specific Location Factors That Contributed to the Accident:

  Drawing

• Type of Accident

  Select Mobile Plant Product Machinery Fall From Height Falling Objects Slips Trips & Falls

  • Mobile Plant
  • Product
  • Machinery
  • Fall From Height
  • Falling Objects
  • Slips Trips & Falls

Accident Sequence: Describe in order of occurrence the events leading to the accident and/or injury. Reconstruct the sequence of events that led to the accident.

• Event 1

• Event 2

• Accident Event:

• Injury Event:

• Photo Evidence

  Media

Causal Factors:

• Describe events and conditions that contributed to the accident. Include information on worker, machinery and equipment, environment and management.

Corrective Actions: Identify the factors listed above that can be corrected to prevent a reoccurrence of this type of accident. Indicate the person responsible for making the change and project a target date for completion of the task. Use the diagram grid below to illustrate layout changes.

• Corrective Actions

  Yes

  No

  N/A

• Target Date for Completion:

• Assignment Responsibilities:

• Pictures:

  Media

• Summary: Include comments that would promote a safe workplace environment and reduce an accidents potential in the future based on review of the causal Factors and implementation of Corrective Actions.

Risk Assessments & Safe Systems of Work

• Risk Assessments Included

  Yes

  No

  N/A

• Safe Systems of Work Included?

  Yes

  No

  N/A

Training Records

• Induction Completed?

  Yes

  No

  N/A

• All Completed Training Records available?

  Yes

  No

  N/A

This Accident Investigation Report was prepared by:

• Signature:

  Sign

• Date:

  Date

• Title:

• Department:

Approved by ( If Corrective action is required.)

• Signature:

  Sign

• Date:

  Date

• Title: