Title Page
Trackwork INITIAL ACCIDENT / INCIDENT REPORT FORM
-
This form must be completed for all accidents, incidents or Near Misses involving Trackwork employees or its contractors and handed to the person in charge ( Line Manager / supervisor / Foreman ) on the day of the accident an forwarded to the HSQE department Team within 24hrs.
DETAILS OF PERSON COMPLETING THIS FORM
-
Name :
-
Position / Grade:
-
Company :
-
Contact Number :
-
Date / Time Reported:
DESCRIPTION OF ACCIDENT / INCIDENT / NEAR MISS
-
Description of what happened: ( provide specific details of activity being undertaken at the time )
-
Senior Person on site :
-
witnesses / others Involved :
DETAILS OF THE INCIDENT
-
Date / Time of Incident:
-
Location Incident occurred:
-
Contract Number / Title :
-
Police been Involved:
-
Crime Number :
-
Emergency Services Required:
-
HDE or EA Involved:
-
Was a Train Involved ?
-
Provide unit number :
-
Was a Road Vehicle Involved ?
-
Provide Reg Number :
-
Tools / Machinery Involved ?
-
Tools / Machinery fit for use ?
-
Weather Conditions:
-
Area made safe ?
-
Add any relevant supporting evidence:
DETAILS OF INJURED PERSON
-
Name :
-
Date of Birth :
-
Position / Grade:
-
Company :
-
Contact Number :
-
Line Managers Name :
-
Hours of work on day of incident
-
To
-
From
-
NATURE OF INJURY / BODY PART AFFECTED
-
Details:
-
Was First Aid administered ?
-
By whom :
-
Detained in hospital more than 24hrs?
-
Was hospital attended ?
-
Was Correct PPE being used ?
-
Safe system of work briefed / understood ?
CAUSE OF INCIDENT AND INITIAL INVESTIGATION
-
Cause of the Incident - Identify initial and underlying causes
-
Remedial / Corrective Actions Completed and Planned to Prevent Recurrence of the Incident
-
Who By:
-
Target Date:
-
Signature of Injured Person :
-
Signature of ( PM, Site Agent or Foreman ) :
