Information
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Audit Title
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Document No.
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Client / Site
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Conducted on
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Prepared by
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Location
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Personnel
Identification of Incident
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Date and Time incident took place
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Date and Time Incident reported
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Incident Reported By
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Where exactly did the incident take place
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Type of Accident
- Slip, Trip, Fall
- Struck by falling or moving object
- Manual Handling Injury
- Violence
- Asphyxiation
- Other
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Result of accident / action
Incident description
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Describe in detail, how the incident occurred.
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Relevant evidential photos
Injured Person(s)
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How many people have been injured
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Name, Address,Date of Birth and Contact details of injured person 1
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In what capacity was the injured person on your premises
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Describe injuries Sustained as a result of this incident
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Severity of injuries sustained
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Name, Address,Date of Birth and Contact details of injured person 2
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In what capacity was the injured person on your premises
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Describe injuries Sustained as a result of this incident
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Severity of injuries sustained
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Name, Address,Date of Birth and Contact details of injured person 3
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In what capacity was the injured person on your premises
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Describe injuries Sustained as a result of this incident
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Severity of injuries sustained
Cause of incident
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Could this incident have been avoided. Was it foreseeable
Enforcement Authorities & Action
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Has the incident been reported under RIDDOR
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Name and Contact Details of EHO (Environmental Health Officer)
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Name and Contact Details of Fire Safety Officer
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What type of enforcement action is being taken.
Investigation Summary
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Investigation Completed by
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Position
