Title Page
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Conducted on
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Prepared by
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Location
Injured Person Background
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Name of Injured Person
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Job Title
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Premises where the accident happened
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Where on the premises did the accident happen
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Accident type
- slip/ trip
- manual handling
- fall from height
- Contact with stationary fixture
- Cut
- Burn
- fall on level
- Hit by moving object
- Chemical exposure
- Entrapment
- Electric Shock
- near miss no injury
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Details of any First Aid given
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Did Injured person attend hospital
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Name of hospital attended and details of treatment given
Injury Details
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Date and time of event
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Description of injury/Near Miss
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What part of the body was injured? Describe in detail
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Take photo of the body part that was injured. Annotate as required
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Give details of events leading up to the accident/Incident and the immediate cause
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What activity was the person undertaking
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Take photo of the surrounding environment the employee was in prior to the event
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Is this part of their job
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Are they trained and authorised to do it
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Was equipment, tools being used?
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Explain what equipment, tools were being used?
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What caused the event?
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Add supporting evidence of contributing factors
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State any PPE specified for this work
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Was the specified PPE being worn
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Recommended preventive action to take in the future to prevent reoccurence
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Is there any CCTV coverage of the area
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Has a copy been requested
Witness Statements
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Were there any witnesses?
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Add witness
Witness
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Enter witness name
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Contact number
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Witness statement
site Management
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Has Accident been reported to site management
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Copy of site accident report requested
Sign off
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Injured person signature
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Supervisor signature
