Site details

  • Site that employee was working at;

  • Employers details

Accident/Incident Details

  • Date and time of injury;

  • Employee Name

  • Job Title:

  • Location of accident (please be specific)

  • Location of accident (please be specific)

  • 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:

Supervision details

  • Was a Risk Assessment completed before work began:

  • HSE Informed?

Injured Party statement

  • Name & Signature of the injured party

Witness statements

  • Witnesses 1

  • Name and signature of the witness 1

  • Witnesses 2

  • Name and signature of the witness 2

  • Witnesses 3

  • Name and signature of the witness 3

Injury Details if Applicable

  • What type of provider performed treatment?

  • Part of Body injured:

  • Will the employee have any restrictions:

  • If so, what are they?

  • Anyone else injured:

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

Supervisor in Charge (please sign below)

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

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

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