• Site

  • Accident reference No.

  • Conducted on

  • Prepared by

  • Location

Accident Investigation Report:

  • Accident Report Number:

  • Company Accident report attached?

  • Has the HSE been Notified?

  • RIDDOR Report added?

  • Accident Date & Time:

Company Information

  • Name:

  • Address:

Employee Information:

  • Name:

  • Home Address:
  • Age:

  • Sex:

  • Department:

  • Job Title:

  • Employee Status:

  • Length of Employment:

  • Time in Occupation at time of accident:

Injury Information:

  • Date & Time Reported:

  • Nature of Injury and Part of Body Affected:

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

  • Was the Employee Working:

  • Severity of Injury:

  • Name and Address of Hospital


  • Name

  • Statement

  • Name

  • Statement Added?

  • Name

  • Statement

  • Name

  • Statement Added

  • Name

  • Statement Added

  • Name

  • Statement Added

Scene of Accident Information:

  • Specific Location:
  • Describe How the Accident Occurred:

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

  • Type of Accident

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

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

  • Target Date for Completion:

  • Assignment Responsibilities:

  • Pictures:

  • 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

  • Safe Systems of Work Included?

Training Records

  • Induction Completed?

  • All Completed Training Records available?

This Accident Investigation Report was prepared by:

  • Signature:

  • Date:

  • Title:

  • Department:

Approved by ( If Corrective action is required.)

  • Signature:

  • Date:

  • Title:

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.