Accident/Incident & Investigation report - duplicate

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Overview

• Date/Time of accident/incident

  Date

AUB Site details

• Location

Accident/Incident Details

• Date and time of injury;

  Date

• Patient's Name

• Status<br>

  Staff

  Student

  Visitor

  Contractor

• Age? (If student)

• Patient's Address

Supervision details

• HSE Informed?

  Yes

  No

  N/A

• Date and Time when the employer was notified:

  Date

Injured Party statement

• Name & Signature of the injured party

  Sign

Witness statements

• Witnesses 1

• Name and signature of the witness 1

  Sign

• Witnesses 2

• Name and signature of the witness 2

  Sign

• Witnesses 3

• Name and signature of the witness 3

  Sign

Injury Details if Applicable

• Where was medical treatment first provided?

• What type of provider performed treatment?

  Select First Aider Paramedic Other

  • First Aider
  • Paramedic
  • Other

• What was the treatment?

• Name of AUB First Aider present

• If you choose other please specify.

• Part of Body injured:

The Accident

• Was anyone else else injured:

  Yes

  No

  N/A

• How did the accident happen? (Note any equipment involved)

• What activities were taking place at the time?

• Was there anything unusual or different about the working conditions? If so .. What?

• Was an Ambulance called?

  Yes

  No

  N/A

• Where was the patient taken by the ambulance?

  Poole Hospital A&E

  Bournemouth Hospital A&E

  Other

Corrective Actions

• Were there adequate safe working procedures and were they followed?

  Yes

  No

  N/A

• Have similar accidents/incidents happened before? (Give details)

Action: Short Term

• Was there immediate action taken to correct the issue (how was this done):

• Who was the responsible party for correcting the issue:

Action: Long Term

• What is the long term action needed to correct the issue: (What risk control measures are needed?)

• Who was the responsible party for correcting the issue:

Follow-Up Procedures

• Posters

  Yes

  No

  N/A

• Personal reminders

  Yes

  No

  N/A

• Safety stickers

  Yes

  No

  N/A

• Briefings

  Yes

  No

  N/A

• Literature

  Yes

  No

  N/A

• Technical Advice

  Yes

  No

  N/A

• Information, Instruction and Training

  Yes

  No

  N/A

Additional Information

• Please provide all attachments that apply: Pictures, Drawings, Training Records, Statements. Note if hazard has been destroyed, removed or is otherwise not available

  Media

• Lessons Learned:

• Which risk assessments and safe working procedures need to be reviewed and updated?

Investigation Conclusions

• Is the above report a true reflection of the Accident / Incident

  Sign

Person Completing Form (please sign below)

• Add signature

  Sign

AUB Health and Safety Officer (please sign below)

• Is the above report a true reflection of the Accident / Incident

  Sign

Injured Party witnessing the completion of the forms agreement with the content and that it is a true reflection of the accident / Incident

• Is the above report a true reflection of the Accident / Incident

  Sign