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

Witnesses:

  • 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:

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