Information
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Document No.
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Audit Title
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Client / Site
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Conducted on
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Prepared by
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Location
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Personnel
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CTL acc/in Ref
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Date and time of occurrence
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CTL task/po/ref number
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Location/ site address of occurrence
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Names of people involved
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Injury &/ or damage caused to:
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Please specify
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Name/type of injured/damaged person/item
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Address of injured/damaged person/item
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Precise nature of injury/damage
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Photographic evidence?
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Description of circumstances, events and actions
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Additional sketch
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Name of injured person
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Address of injured person
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Precise nature of injury
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Photographic evidence?
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Description of circumstances, events and actions
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Additional sketch
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Type of service, vehicle or property which incurred damage
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Address of damaged item
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Precise nature of damage
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Photographic evidence?
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Description of circumstances, evens and actions
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Additional sketch
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Where any of these contacted?
- Police
- Ambulance
- Fire brigade
- Utility provider
- Insurance
- Other
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Please specify
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Was any first aid administrated?
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What and by whom
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What happened to the injured person following the incident/accident & any administration of first aid?
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Please specify
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Details of any immediate corrective action taken following the occurrence, and by whom:
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I agree that all of the above facts are a true record of the occurrence; accident; incident or near miss
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Name and signature
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Date signed
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TO BE COMPLETED BY MANAGEMENT
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Following a review of the information provided, the company has determined the following action(s) are required
- Accident book to be completed
- Review of risk assessments
- Review of method statements
- Internal investigation
- Tool box talk
- Riddor (HSE) reportable
- Panel of enquiry (serious)
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Date action taken
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Conclusion statement from review
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Actions required/ taken from review
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Name and signature
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Results from investigation
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Actions required/taken from investigation
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Name and signature
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I confirm this accident/incident review/investigation had been concluded and all actions required, satisfied
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Name and signature
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Date signed
