Accident Template

• Site conducted

• Conducted on

  Date

• Prepared by

• Location
  Address

• To:

• Cc:

• From:

• Date:

  Date

• Date and time of Accident

  Date
• Location
  Address

• Person(s) involved

• Description of events

• Any underlying causes or aggravating / mitigating factors?

• Immediate Action taken

• Further action required

• Witnesses:

• Personnel named in this report

• Supporting evidence attached: interviews, statements, correspondence, records, photographs

  Media

• Summary and conclusions:

Investigation conducted by:

• Steve Tate CMIOSH

  Sign