Accident/Incident & Investigation Report

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Site details

• Site that employee was working at;

• Employers details

Accident/Incident Details

• Date and time of injury;

  Date

• Employee Name

• Job Title:

  Select Setter Toolmaker Electro Plater Labourer Supervisor Forklift driver Manager Operator Electrician Apprentice Driver Packer Check weigher

  • Setter
  • Toolmaker
  • Electro Plater
  • Labourer
  • Supervisor
  • Forklift driver
  • Manager
  • Operator
  • Electrician
  • Apprentice
  • Driver
  • Packer
  • Check weigher

• Location of accident (please be specific)

• Location of accident (please be specific)

  Select Rollfeed Powerpress Handpress Bracker Toolroom Stores Steel Stores Packing Car Park Rear Yard Plating Shop

  • Rollfeed
  • Powerpress
  • Handpress
  • Bracker
  • Toolroom
  • Stores
  • Steel Stores
  • Packing
  • Car Park
  • Rear Yard
  • Plating Shop

• Nature of Incident or Injury

• Describe who, what, when,where, why and how injury occurred:

• Contributing causes of the Incident: (Inadequate training, Inadequate supervision. Employee not following proper safety procedures and instructions)

• Possible Cause or Causes of the incident: (Inadequate PPE, Not Paying attention to surroundings, failure to utilise safety equipment)

• What is the employee's current status if injured: Describe. ( Returned to work the next day, off of work do to injury, off of work do to restrictions, In hospital, etc.)

• Severity:

  First Aid Only

  Reportable

  Lost Time

  Restricted Duty

  Fatality

Supervision details

• Was a Risk Assessment completed before work began:

  Yes

  No

  N/A

• HSE Informed?

  Yes

  No

  N/A

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

• What type of provider performed treatment?

  GP

  A&E Hospital

  On-Site First Aid

• Part of Body injured:

• Will the employee have any restrictions:

  No

  Yes

• If so, what are they?

• Anyone else injured:

  Yes

  No

  N/A

Corrective Actions

Action: Short Term

• What was the 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:

• Who was the responsible party for correcting the issue:

Investigation Conclusions

Person Completing Form (please sign below)

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

  Sign

Supervisor in Charge (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