Investigation

Investigation Details

Who will be leading this investigation?

Who will assist in this investigation

Please enter the date of this investigation.

What kind of incident are you investigating?

Please add the accident/dangerous occurrence reference number this investigation relates too.

Incident Details

Name of injured person (if any)

Address
When did the incident occur?

What type of person was injured? (if any)

Which part of the body was injured? (if any)

Give details of any tasks being carried out at the time of the incident/injury?

Have all persons involved in the incident received information, instruction and training for the tasks relating to the incident?

Describe in detail what happened?

Describe in detail any injury sustained, if no injury, describe any damaged equipment, plant or machinery etc

Do you think any persons involved in the incident are negligent in any way, if yes, describe how.

Please add as many images as you can that relate to the incident.

List all witnesses of the incident

Medical Treatment

Was First Aid administered on-site

Describe what assistance was provided by the First Aider, list any medical equipment used (plasters, bandage, eyewash etc.)

Obtain signature of First Aider
Did you require any further treatment?

What was the outcome of this?

Please provide dates and times
Witness Statement 1

Please interview all witnesses and ask for signatures

Name

Address
I confirm that the information I have provided in relation to this incident is accurate.
Select date
Witness Statement 2

Please interview all witnesses and ask for signatures

Name

Address
I confirm that the information I have provided in relation to this incident is accurate.
Select date
How did the incident/injury occur?
Please list the main cause or causes of this incident or injury
Please list any contributing factor or factors relating to this incident or injury

Describe in detail your findings as to how the incident has occurred?

Corrective and Preventive Action

What corrective actions have been taken immediately?

Who carried out the corrective actions?

Describe what actions can be taken to prevent a recurrence of this incident (Improved training, PPE, improved housekeeping, improved maintenance etc)

Provide a monthly timescale for any improvements that will be made?
Incident Reporting

Did the injured person require time off work

Results of Investigation

Explain the results of your findings, take into account all factors and provide a balanced view, if there is a clear cause for the incident, be sure to list it.

If any equipment, plant, machinery have been damaged please list and describe the issues

Authorisation

I agree that all information provided by this investigation is accurate.

Signed by injured person
Signed by Lead Investigator
Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.