Accident report

• Site conducted

  Select

• Client / Site

  Select Equans/Engie HG Construction Wates Barratts Mullaly Durkan JerramFalkus Farrans Higgins Other

  • Equans/Engie
  • HG Construction
  • Wates
  • Barratts
  • Mullaly
  • Durkan
  • JerramFalkus
  • Farrans
  • Higgins
  • Other

• Conducted on

  Date

• Prepared by

• Investigator(s)

• Type of occurrence

  Catastrophic

  Major

  Moderate

  Minor

  Insignificant

• Investigation level

  High Level

  Medium Level

  Low Level

  Basic

• Time and Date of the occurrence

  Date

• Name of injured party

• Details of Injury?

  Select Head Eye Arm Trunk Hand Leg Feet

  • Head
  • Eye
  • Arm
  • Trunk
  • Hand
  • Leg
  • Feet

• Nature of Injury?

  Select Sprain, strain, fracture or break. Open wound, cut or abrasion Bruising Burns and scalds Concussion Amputation Hernias, slipped disc or back Property damage RIDDOR

  • Sprain, strain, fracture or break.
  • Open wound, cut or abrasion
  • Bruising
  • Burns and scalds
  • Concussion
  • Amputation
  • Hernias, slipped disc or back
  • Property damage
  • RIDDOR

• First aid treatment?

  Yes

  No

  N/A

• Details of first aid treatment?

• Location of incident
  Address

• Training and documentations records

  Yes

  No

  N/A

• Entry in accident book.

• Risk Assessment and Method Statement-(RAMS) in site & signed the record sheet.

• Permit to work.

• Other.

• What task was being carried out?

• What plant and equipment was used for the task?

• Immediate Cause

• Underlying Cause

• Root Cause

• Were the emergency services called?

  Yes

  No

  N/A

• Details

Investigation and reporting

• Is the incident reportable under RIDDOR? (injured party taken from site to hospital, injury or work related illness resulting in more than 7 days off work, specified dangerous occurance

  Yes

  No

  N/A

• What corrective action can you take to prevent reoccurrence?

• Does the occurrence require further investigation? (Please contact ESS SHEQ Department on 01708867609 immediately and leave as much of the scene un touched as possible, take photographs of the scene)

  Yes

  No

  N/A

• Signature of injured party or representative

  Sign

• Investigator Signature

  Sign