Title Page
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Title of incident
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Site Name
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Investigation conducted on
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Completed by
Incident Details
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Date & Time of Incident
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Location of Incident
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Please add a photo(s) of the exact area if possible.
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Incident Type (select all that apply)
- Hazard
- Near-Miss
- Accident
- Theft
- Fire
- Property Damage
- Cable Strike
- Illness
- Other
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Please describe type of incident
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Name of on-duty Manager, Assistant Manager at time of incident?
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Incident Severity? (only where injury or possible injuries occurred)
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Fatal: Work-related death;
Major injury/ill health: (as defined in RIDDOR, Schedule 1), including fractures (other than fingers or toes), amputations, loss of sight, a burn or penetrating injury to the eye,
any injury acute illness resulting in unconsciousness, requiring resuscitation or requiring admittance to hospital for more than 24 hours;
Serious injury/ill health: Where the person affected is unfit to carry out his or her normal work for more than three consecutive days;
Minor injury: All other injuries, where the injured person is unfit for his or her normal work for less than three days; -
Investigation Level? (for all non injury or possible injury related events a high level investigation level should be carried out)
Incident Summary
-
Describe what happened. Please be detailed but state only facts.
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What were the weather / environmental conditions at the time of the incident?
- Clear
- Cloudy
- Rain
- Snow
- Windy
- Heatwave
- Haze
- Other
-
Describe the weather / environmental conditions at the time of the incident
People involved
-
Please document all people involved in this incident
Person
Person
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Full Name
-
Induction number
-
Contact phone number
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What is this person's relation to the incident? (select all that apply)
- Reporter of incident
- Injured person
- Witness
- Primary person involved
- Secondary Involvement
- On-duty supervisor
- Investigator
- Suspect
- Other
-
Describe this person's relation to the incident
-
Please describe this person's involvement with the incident, including all relevant information
-
Attach any relevant photos regarding this person
-
Do you want to log a statement for this person?
Statement
-
For your consideration - take the persons details - what time was it - where were they - what were they doing there - where they meant to be there - did they see the event or just the before and after - if they saw the event then who was doing what - what was said - where they meant to be doing it, if not why were they doing it etc......
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Statement regarding incident
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A photo of a signed written statement is acceptable.
-
Person Signature if not provided on media
-
Date & Time of Statement
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Has this person sustained an injury?
Injury Details
-
Type of injury or illness? (select all that apply)
- Superficial
- Open Wound
- Fatality
- Concussion
- Sprain
- Respiratory
- Eye Injury
- Burns
- Fracture
- Electrocution
- Fall
- Strain
- Dislocation
- Struck by object
- Entanglement
- Assault
- Muscle & Tendon
- Nerve & Spinal Cord
- Amputation
- Intracranial
- Other
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Describe type of injury or illness
-
Parts of body affected? (select all that apply)
- General Ailment
- Head
- Eye (Right)
- Eye (Left)
- Ear
- Nose
- Throat
- Neck
- Back (Upper)
- Back (Lower)
- Arm - Upper (Right)
- Arm - Upper (Left)
- Arm - Elbow (Right)
- Arm - Elbow (Left)
- Arm - Forearm (Right)
- Arm - Forearm (Right)
- Wrist (Right)
- Wrist (Left)
- Hand (Right)
- Hand (Left)
- Chest
- Abdominal / Stomach
- Groin / Anus
- Leg - Upper (Right)
- Leg - Upper (Left)
- Leg - Knee (Right)
- Leg - Knee (Left)
- Leg - Lower (Right)
- Leg - Lower (Left)
- Ankle (Right)
- Ankle (Left)
- Foot (Right)
- Foot (Left)
- Shoulder (Left)
- Shoulder (Right)
- Other
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Please describe injury location
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Describe this injury or illness
-
What was the cause of this injury or illness?
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Was medical attention administered/required?
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What kind of medical attention was administered?
- First Aid
- Doctor Consulted
- Hospital
- Ambulance
- Medical Attention Declined
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Please detail medical attention
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Please add photos on injuries if possible.
Tier one manager Sign Off
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Further action/follow-up/investigation required?
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Name of person/people to follow up
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Name & Signature of Investigator
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Name of tier 2 manager who has been made aware of the incident.
Incident Summary
-
Describe what happened. Please be detailed but state only facts.
-
What were the weather / environmental conditions at the time of the incident?
- Clear
- Cloudy
- Rain
- Snow
- Windy
- Heatwave
- Haze
- Other
-
Describe the weather / environmental conditions at the time of the incident
People involved
-
Please document all people involved in this incident
Person
Person
-
Full Name
-
Induction number
-
Contact phone number
-
What is this person's relation to the incident? (select all that apply)
- Reporter of incident
- Injured person
- Witness
- Primary person involved
- Secondary Involvement
- On-duty supervisor
- Investigator
- Suspect
- Other
-
Describe this person's relation to the incident
-
Please describe this person's involvement with the incident, including all relevant information
-
Attach any relevant photos regarding this person
-
Do you want to log a statement for this person?
Statement
-
For your consideration - take the persons details - what time was it - where were they - what were they doing there - where they meant to be there - did they see the event or just the before and after - if they saw the event then who was doing what - what was said - where they meant to be doing it, if not why were they doing it etc......
-
Statement regarding incident
-
A photo of a signed written statement is acceptable.
-
Person Signature if not provided on media
-
Date & Time of Statement
-
Has this person sustained an injury?
Injury Details
-
Type of injury or illness? (select all that apply)
- Superficial
- Open Wound
- Fatality
- Concussion
- Sprain
- Respiratory
- Eye Injury
- Burns
- Fracture
- Electrocution
- Fall
- Strain
- Dislocation
- Struck by object
- Entanglement
- Assault
- Muscle & Tendon
- Nerve & Spinal Cord
- Amputation
- Intracranial
- Other
-
Describe type of injury or illness
-
Parts of body affected? (select all that apply)
- General Ailment
- Head
- Eye (Right)
- Eye (Left)
- Ear
- Nose
- Throat
- Neck
- Back (Upper)
- Back (Lower)
- Arm - Upper (Right)
- Arm - Upper (Left)
- Arm - Elbow (Right)
- Arm - Elbow (Left)
- Arm - Forearm (Right)
- Arm - Forearm (Right)
- Wrist (Right)
- Wrist (Left)
- Hand (Right)
- Hand (Left)
- Chest
- Abdominal / Stomach
- Groin / Anus
- Leg - Upper (Right)
- Leg - Upper (Left)
- Leg - Knee (Right)
- Leg - Knee (Left)
- Leg - Lower (Right)
- Leg - Lower (Left)
- Ankle (Right)
- Ankle (Left)
- Foot (Right)
- Foot (Left)
- Shoulder (Left)
- Shoulder (Right)
- Other
-
Please describe injury location
-
Describe this injury or illness
-
What was the cause of this injury or illness?
-
Was medical attention administered?
-
What kind of medical attention was administered?
-
Please detail medical attention
-
Please add photos on injuries if possible.
Root Cause Analysis / Contributing Factors
-
What were the contributing factors to this incident occurring? (select all that apply)
- Equipment Defects
- Unauthorized Equipment Use
- Improper Equipment Use
- Lack of protective safety devices
- Employee operating at inappropriate speed
- Equipment used outside rated capacity
- Lack of PPE
- Inappropriate PPE
- Untidy Conditions (Poor Housekeeping)
- Safety procedures not followed
- Inadequate ventilation
- Drugs or Alcohol
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Has the root cause of this issue been able to be identified?
-
Why is the root cause for this issue unable to be identified at this time?
-
How likely is this incident to reoccur in future?
- Certain
- Very Likely
- Likely
- Unlikely
- Very Unlikely
- Never
- Unclear / Not Determinable
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What is the root cause of this incident? Please consider and include all contributing factors
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Has the root cause of this issue been rectified or eliminated?
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How was the root cause rectified or eliminated?
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Please attach any relevant photos or media
-
Please provide any relevant further details
-
How likely is this incident to reoccur in future?
- Certain
- Very Likely
- Likely
- Unlikely
- Very Unlikely
- Never
- Unclear / Not Determinable
Corrective Actions
-
Are corrective/further actions required with regard to this incident?
-
Please add any corrective actions to the appropriate questions above before completing this incident investigation
-
Have all required corrective actions been added as Actions to this inspection?
Tier one management Sign Off
-
Name and position of Tier one manager
-
Further action/follow-up/investigation required?
-
Name of person/people to follow up
-
Name & Signature of Investigator
Tier two management Sign Off
-
Name and position of Tier two manager
-
Comments following the incident including a review of current and proposed controls.
-
Name and signature of tier two manager.
Incident Summary
-
Describe what happened. Please be detailed but state only facts.
-
What were the weather / environmental conditions at the time of the incident?
- Clear
- Cloudy
- Rain
- Snow
- Windy
- Heatwave
- Haze
- Other
-
Describe the weather / environmental conditions at the time of the incident
People involved
-
Please document all people involved in this incident
Person
Person
-
Full Name
-
Induction number
-
Contact phone number
-
What is this person's relation to the incident? (select all that apply)
- Reporter of incident
- Injured person
- Witness
- Primary person involved
- Secondary Involvement
- On-duty supervisor
- Investigator
- Suspect
- Other
-
Describe this person's relation to the incident
-
Please describe this person's involvement with the incident, including all relevant information
-
Attach any relevant photos regarding this person
-
Do you want to log a statement for this person?
Statement
-
For your consideration - take the persons details - what time was it - where were they - what were they doing there - where they meant to be there - did they see the event or just the before and after - if they saw the event then who was doing what - what was said - where they meant to be doing it, if not why were they doing it etc......
-
Statement regarding incident
-
A photo of a signed written statement is acceptable.
-
Person Signature if not provided on media
-
Date & Time of Statement
-
Has this person sustained an injury?
Injury Details
-
Type of injury or illness? (select all that apply)
- Superficial
- Open Wound
- Fatality
- Concussion
- Sprain
- Respiratory
- Eye Injury
- Burns
- Fracture
- Electrocution
- Fall
- Strain
- Dislocation
- Struck by object
- Entanglement
- Assault
- Muscle & Tendon
- Nerve & Spinal Cord
- Amputation
- Intracranial
- Other
-
Describe type of injury or illness
-
Parts of body affected? (select all that apply)
- General Ailment
- Head
- Eye (Right)
- Eye (Left)
- Ear
- Nose
- Throat
- Neck
- Back (Upper)
- Back (Lower)
- Arm - Upper (Right)
- Arm - Upper (Left)
- Arm - Elbow (Right)
- Arm - Elbow (Left)
- Arm - Forearm (Right)
- Arm - Forearm (Right)
- Wrist (Right)
- Wrist (Left)
- Hand (Right)
- Hand (Left)
- Chest
- Abdominal / Stomach
- Groin / Anus
- Leg - Upper (Right)
- Leg - Upper (Left)
- Leg - Knee (Right)
- Leg - Knee (Left)
- Leg - Lower (Right)
- Leg - Lower (Left)
- Ankle (Right)
- Ankle (Left)
- Foot (Right)
- Foot (Left)
- Shoulder (Left)
- Shoulder (Right)
- Other
-
Please describe injury location
-
Describe this injury or illness
-
What was the cause of this injury or illness?
-
Was medical attention administered?
-
What kind of medical attention was administered?
-
Please detail medical attention
-
Please add photos on injuries if possible.
Evidence and Attachments
-
Which of the following do you need to attach to this report to accuractly document this incident?
- Evidence
- Equipment Details
- Vehicle Details
- Damages
- Other Items
Evidence Log
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Please log all relevant evidence below
Evidence
-
Evidence Name and Description
-
Evidence ID number (if applicable)
-
Type of evidence
-
Photos of evidence (if applicable)
-
Please detail any further information regarding this evidence (if applicable)
Vehicle Log
-
Please log all relevant vehicle details below
Vehicle
-
Vehicle Name and Make
-
Vehicle Model
-
Vehicle Registration
-
Driver (if applicable)
-
Photos of equipment (if applicable)
-
Please detail any further information regarding this vehicle (if applicable)
Damage Log
-
Please log all relevant damage details below
Damage
-
Damage description
-
ID number (if applicable)
-
Photos of damage (if applicable)
-
Please detail any further information regarding this damage (if applicable)
Other Items Log
-
Please log all relevant details of other items below
Item
-
Item description
-
ID number (if applicable)
-
Photos of item (if applicable)
-
Please detail any further information regarding this item (if applicable)
Equipment Log
-
Please log all relevant equipment details below
Equipment
-
Equipment Name and Make
-
Equipment Model
-
Equipment ID number (if applicable)
-
Photos of equipment (if applicable)
-
Please detail any further information regarding this equipment (if applicable)
Root Cause Analysis / Contributing Factors
-
What were the contributing factors to this incident occurring? (select all that apply)
- Equipment Defects
- Unauthorized Equipment Use
- Improper Equipment Use
- Lack of protective safety devices
- Employee operating at inappropriate speed
- Equipment used outside rated capacity
- Lack of PPE
- Inappropriate PPE
- Untidy Conditions (Poor Housekeeping)
- Safety procedures not followed
- Inadequate ventilation
- Drugs or Alcohol
-
Has the root cause of this issue been able to be identified?
-
Why is the root cause for this issue unable to be identified at this time?
-
How likely is this incident to reoccur in future?
- Certain
- Very Likely
- Likely
- Unlikely
- Very Unlikely
- Never
- Unclear / Not Determinable
-
What is the root cause of this incident? Please consider and include all contributing factors
-
Has the root cause of this issue been rectified or eliminated?
-
How was the root cause rectified or eliminated?
-
Please attach any relevant photos or media
-
Please provide any relevant further details
-
How likely is this incident to reoccur in future?
- Certain
- Very Likely
- Likely
- Unlikely
- Very Unlikely
- Never
- Unclear / Not Determinable
Corrective Actions
-
Are corrective/further actions required with regard to this incident?
-
Please add any corrective actions to the appropriate questions above before completing this incident investigation
-
Have all required corrective actions been added as Actions to this inspection?
Tier one management Sign Off
-
Name and position of Tier one manager
-
Further action/follow-up/investigation required?
-
Name of person/people to follow up
-
Name & Signature of Investigator
Tier two management Sign Off
-
Name and position of Tier two manager
-
Comments following the incident including a review of current and proposed controls.
-
Name and signature of tier two manager.
SMT Sign Off
-
Due to the severity of the incident a meeting must be scheduled to ensure all areas have been reviewed, all root causes have been identified and actions have been set/rectified.
-
Name of SMT member reviewing the incident.
-
Date and time of meeting.
-
Please give details of the meeting including - all people present - Thoughts of the SMT member - a review of the root cause analysis - review of further controls/actions required including people responsible and timescales.
-
Name and signature of SMT member.
Incident Summary
-
Describe what happened. Please be detailed but state only facts.
-
What were the weather / environmental conditions at the time of the incident?
- Clear
- Cloudy
- Rain
- Snow
- Windy
- Heatwave
- Haze
- Other
-
Describe the weather / environmental conditions at the time of the incident
People involved
-
Please document all people involved in this incident
Person
Person
-
Full Name
-
Induction number
-
Contact phone number
-
What is this person's relation to the incident? (select all that apply)
- Reporter of incident
- Injured person
- Witness
- Primary person involved
- Secondary Involvement
- On-duty supervisor
- Investigator
- Suspect
- Other
-
Describe this person's relation to the incident
-
Please describe this person's involvement with the incident, including all relevant information
-
Attach any relevant photos regarding this person
-
Do you want to log a statement for this person?
Statement
-
For your consideration - take the persons details - what time was it - where were they - what were they doing there - where they meant to be there - did they see the event or just the before and after - if they saw the event then who was doing what - what was said - where they meant to be doing it, if not why were they doing it etc......
-
Statement regarding incident
-
A photo of a signed written statement is acceptable.
-
Person Signature if not provided on media
-
Date & Time of Statement
-
Has this person sustained an injury?
Injury Details
-
Type of injury or illness? (select all that apply)
- Superficial
- Open Wound
- Fatality
- Concussion
- Sprain
- Respiratory
- Eye Injury
- Burns
- Fracture
- Electrocution
- Fall
- Strain
- Dislocation
- Struck by object
- Entanglement
- Assault
- Muscle & Tendon
- Nerve & Spinal Cord
- Amputation
- Intracranial
- Other
-
Describe type of injury or illness
-
Parts of body affected? (select all that apply)
- General Ailment
- Head
- Eye (Right)
- Eye (Left)
- Ear
- Nose
- Throat
- Neck
- Back (Upper)
- Back (Lower)
- Arm - Upper (Right)
- Arm - Upper (Left)
- Arm - Elbow (Right)
- Arm - Elbow (Left)
- Arm - Forearm (Right)
- Arm - Forearm (Right)
- Wrist (Right)
- Wrist (Left)
- Hand (Right)
- Hand (Left)
- Chest
- Abdominal / Stomach
- Groin / Anus
- Leg - Upper (Right)
- Leg - Upper (Left)
- Leg - Knee (Right)
- Leg - Knee (Left)
- Leg - Lower (Right)
- Leg - Lower (Left)
- Ankle (Right)
- Ankle (Left)
- Foot (Right)
- Foot (Left)
- Shoulder (Left)
- Shoulder (Right)
- Other
-
Please describe injury location
-
Describe this injury or illness
-
What was the cause of this injury or illness?
-
Was medical attention administered?
-
What kind of medical attention was administered?
-
Please detail medical attention
-
Please add photos on injuries if possible.
Evidence and Attachments
-
Which of the following do you need to attach to this report to accuractly document this incident?
- Evidence
- Equipment Details
- Vehicle Details
- Damages
- Other Items
Evidence Log
-
Please log all relevant evidence below
Evidence
-
Evidence Name and Description
-
Evidence ID number (if applicable)
-
Type of evidence
-
Photos of evidence (if applicable)
-
Please detail any further information regarding this evidence (if applicable)
Vehicle Log
-
Please log all relevant vehicle details below
Vehicle
-
Vehicle Name and Make
-
Vehicle Model
-
Vehicle Registration
-
Driver (if applicable)
-
Photos of equipment (if applicable)
-
Please detail any further information regarding this vehicle (if applicable)
Damage Log
-
Please log all relevant damage details below
Damage
-
Damage description
-
ID number (if applicable)
-
Photos of damage (if applicable)
-
Please detail any further information regarding this damage (if applicable)
Other Items Log
-
Please log all relevant details of other items below
Item
-
Item description
-
ID number (if applicable)
-
Photos of item (if applicable)
-
Please detail any further information regarding this item (if applicable)
Equipment Log
-
Please log all relevant equipment details below
Equipment
-
Equipment Name and Make
-
Equipment Model
-
Equipment ID number (if applicable)
-
Photos of equipment (if applicable)
-
Please detail any further information regarding this equipment (if applicable)
Root Cause Analysis / Contributing Factors
-
What were the contributing factors to this incident occurring? (select all that apply)
- Equipment Defects
- Unauthorized Equipment Use
- Improper Equipment Use
- Lack of protective safety devices
- Employee operating at inappropriate speed
- Equipment used outside rated capacity
- Lack of PPE
- Inappropriate PPE
- Untidy Conditions (Poor Housekeeping)
- Safety procedures not followed
- Inadequate ventilation
- Drugs or Alcohol
-
Has the root cause of this issue been able to be identified?
-
Why is the root cause for this issue unable to be identified at this time?
-
How likely is this incident to reoccur in future?
- Certain
- Very Likely
- Likely
- Unlikely
- Very Unlikely
- Never
- Unclear / Not Determinable
-
What is the root cause of this incident? Please consider and include all contributing factors
-
Has the root cause of this issue been rectified or eliminated?
-
How was the root cause rectified or eliminated?
-
Please attach any relevant photos or media
-
Please provide any relevant further details
-
How likely is this incident to reoccur in future?
- Certain
- Very Likely
- Likely
- Unlikely
- Very Unlikely
- Never
- Unclear / Not Determinable
Corrective Actions
-
Are corrective/further actions required with regard to this incident?
-
Please add any corrective actions to the appropriate questions above before completing this incident investigation
-
Have all required corrective actions been added as Actions to this inspection?
Tier one management Sign Off
-
Name and position of Tier one manager
-
Further action/follow-up/investigation required?
-
Name of person/people to follow up
-
Name & Signature of Investigator
Tier two management Sign Off
-
Name and position of Tier two manager
-
Comments following the incident including a review of current and proposed controls.
-
Name and signature of tier two manager.
MD and SMT Sign Off
-
Due to the severity of the incident a meeting must be scheduled to ensure all areas have been reviewed, all root causes have been identified and actions have been set/rectified.
-
Name of MD and SMT members reviewing the incident.
-
Date and time of meeting.
-
Please give details of the meeting including - all people present - Thoughts of the SMT member - a review of the root cause analysis - review of further controls/actions required including people responsible and timescales.
-
Name and signature of MD.
-
