Identification of Incident

  • Date and Time incident took place

  • Date and Time Incident reported

  • Incident Reported By

  • Where exactly did the incident take place

  • Type of Accident

  • Result of accident / action

  • Has this incident resulted in staff member being off work

  • If Incident resulted in staff member being off work. How long have they been off for

Incident description

  • Describe in detail, how the incident occurred.

  • Diagram of incident location

  • Relevant evidential photos

  • Was the person or persons involved permitted to be carrying out the tasks

  • Was the person or persons involved, trained on how to carry out the task

  • Photo of Training Docs

  • Describe what equipment was involved EG: Step Ladders, Shelving, Tools etc

  • Was the equipment being used, suitable for purpose. Has it been checked.

  • If equipment was found to be unsuitable, what faults were identified and describe what action has been taken.

  • Photo of equipment being used during the incident.

Injured Person(s)

  • How many people have been injured

  • Name, Address,Date of Birth and Contact details of injured person 1

  • In what capacity was the injured person on your premises

  • Describe injuries Sustained as a result of this incident

  • Severity of injuries sustained

  • Name, Address,Date of Birth and Contact details of injured person 2

  • In what capacity was the injured person on your premises

  • Describe injuries Sustained as a result of this incident

  • Severity of injuries sustained

  • Name, Address,Date of Birth and Contact details of injured person 3

  • In what capacity was the injured person on your premises

  • Describe injuries Sustained as a result of this incident

  • Severity of injuries sustained

Cause of incident

  • What do you believe to be the root cause 1 of the incident

  • What do you believe to be the root cause 2 of the incident

  • What do you believe to be the root cause 3 of the incident

  • Explain your reasons / evidence to support the causation theory.

  • Could this incident have been avoided. Was it foreseeable

Recommendation for additional Control Measures

  • What are your recommendations to prevent re-occurrence. Describe additional control measures required or relevant action required.

  • Have control measures been implemented

  • How would you now rate the hazard status, following your implemented control measures

Enforcement Authorities & Action

  • Has the incident been reported under RIDDOR

  • Name and Contact Details of EHO (Environmental Health Officer)

  • Name and Contact Details of Fire Safety Officer

  • What type of enforcement action is being taken.

Investigation Summary

  • Investigation Completed by

  • Position

  • Other persons involved in investigation process / Site Manager

  • Position

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. Any ratings or scores displayed in our Public Library have not been verified by SafetyCulture for accuracy. Users of our platform may provide a rating or score that is incorrect or misleading. You should independently determine whether the template is suitable for your circumstances. You can use our Public Library to search based on criteria such as industry and subject matter. Search results are based on their relevance to your search and other criteria. We may feature checklists based on subject matters we think may be of interest to our customers.