Accident Investigation

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Location of Accident

• Add location
  Address

• Location Photo

  Media

• Location of Accident in Location

Injured Person Details

• Person Type

  Select Employee Customer Contractor Work Experience Temp Other

  • Employee
  • Customer
  • Contractor
  • Work Experience
  • Temp
  • Other

• Name

• Age

• Date of Birth

  Date

• Address

• Job Title

• Length of Time with Company

Training Records

• Confirm Evidence of Training for employees

• Induction Training

• Manual Handling

• Working at Heights / Access Equipment

• Accident Reporting

• Comments Regarding Training

Accident Details

• Date of Accident

  Date

• Accident Type

  Injury

  Ill Health

  Near Miss

  Other

• Potential for Harm

  Select Fatal Major Serious Minor Non Injury Damage Only

  • Fatal
  • Major
  • Serious
  • Minor
  • Non Injury
  • Damage Only

• Accident Description

• RIDDOR

• Not RIDDOR reportable

• RIDDOR ref

• Date Repoted

  Date

• Who Reported

• Insurers Notified

• You should notify your insurers of all serious accidents and incidents

• Who Notified

• When Notified

  Date

Investigation Information Gathering

• How Did the adverse event happen

• What activities where being carried out at the time?

• Anything unusual or different about the working conditions?

• We're there adequate safe working procedures and were they followed?

• Nature and extent of injuries and ill health effects, if any.

• If there was an injury, how did it occur and what caused it?

• Was the risk know? If so, why wasn't it controlled?

• Did the organisational arrangements of the work influence the adverse event?

• Was maintenance and cleaning sufficient. Did it influence the adverse event?

• We're the people involved competent and suitable?

• Did the workplace layout influence the event?

• Did the nature or shape of materials influence the adverse event?

• Did difficulties using plant or equipment influence the adverse event?

• Was safety equipment provided and was it adequate?

• Did any other conditions influence the adverse event?

Photographic Evidence

Photo Evidence

• Issue or Description

• Photo

  Media

Control Risk Measures

• The following control measures are recomended.

Control Measure

• Control Measure

Documentation Review

• The following documentation should be reviewed as a result of this adverse event

• Safety Policy

• Safety Arrnagements

• Safety Responsibilities

• Risk Assessments

• Safe Operating Procedures

• Training

• Other documentation to be reviewed?

Risk Control Actions

• The following action plan should be carried out

Actions

• Action or Control

• To be completed by

  Date

Sign Off

• This investigation was competed on the date and time stated and all areas of note where raised with the location management at the time of the report completion.

• Add signature

  Sign

Report Circulation

• This report should be circulated to the following groups and or people

• Person Responsible for Health and Safety

• Insurance Manager

• Finance Director

• HR Manager

• Property Manager

• Facilities Manager

• Retail Manager

Circulation to Outside Agencies

• HSE / EHO

• Insurance Provider

• Safety Advisor

Other Circulation

• Tis report should also be circulated to the following groups

• Other Circulation