ATC MIDWEST INCIDENT / ACCIDENT INVESTIGATION REPORT

• THIS REPORT IS SUBJECT TO LEGAL PROFESSIONAL PRIVILEGE

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

SECTION 1: INJURED PERSON DETAILS

• NAME:

• AGE:

• INJURED PERSON ADDRESS:
  Address

• PHONE:

• JOB TITLE:

• TIME ON THE JOB: (years, months)

SECTION 2: DETAILS OF THE INCIDENT

• DATE & TIME OF INCIDENT:

  Date

• DATE & TIME REPORTED:

  Date

• WHO WAS THE INCIDENT REPORTED TO?

• SITE SUPERVISOR DETAILS:

• WERE THERE ANY WITNESSES? (Provide details if yes)

  Yes

  No

  N/A
• WHERE DID THE INCIDENT OCCUR?
  Address

• WAS THERE AN INJURY?

  Yes

  No

  N/A

• WHAT WAS THE SEVERITY OF THE INJURY / INCIDENT?

  Minor Injury

  First Aid Injury

  Medical Treatment Injury

  Lost Time Injury

  Reportable Injury / Incident

• WHAT MEDICAL AID HAS BEEN PROVIDED TO THE INJURED PERSON? (1st aid, medications, surgical procedures)

• WAS THE INJURED PERSON ADMITTED TO A HOSPITAL OVERNIGHT?

  Yes

  No

  N/A

SECTION 3 DESCRIPTION OF THE INCIDENT:

• DESCRIBE WHAT WAS HAPPENING AT THE INCIDENT SITE JUST PRIOR TO THE INCIDENT: (work being done, plant in use etc)

• WHAT WAS THE INJURED PERSON DOING AT THE MOMENT THE INCIDENT OCCURED?

• WHAT HAPPENED TO CAUSE THE INJURY?

• Add media

  Media

SECTION 4 CONTRIBUTING FACTORS:

• WERE HUMAN FACTORS INVOLVED IN THE INCIDENT? (eg competency level, training, adherence to work procedures, fitness for work, inexperience, rushing to complete work)

  Yes

  No

  N/A

• WERE THERE PLANT & EQUIPMENT ISSUES INVOLVED IN THE INCIDENT?

  Yes

  No

  N/A

• WERE THERE ANY ENVIRONMENTAL ISSUES INVOLVED IN THE INCIDENT?<br><br>

  Yes

  No

  N/A

• WERE THERE ANY PROCEDURAL OR PROCESS FACTORS INVOLVED IN THE INCIDENT?

  Yes

  No

  N/A

• WAS A RISK ASSESSMENT REQUIRED AND / OR CARRIED OUT PRIOR TO THE INCIDENT? (If not, would a risk assessment likely have prevented the incident?)

  Yes

  No

  N/A

SECTION 5 CORRECTIVE ACTION: Explain what is required to ensure the problems that have been identified can be eliminated or effectively controlled WHS Coordinator to detail recommendations here.

• 1: ELIMINATION

• 2: SUBSTITUTION / REPLACEMENT

• 3: ENGINEERING CONTROL

• 4: ADMINISTRATIVE CONTROL

• 5: USE PERSONAL PROTECTIVE EQUIPMENT

COMMENTS & MANAGEMENT SIGN-OFF

• WHS Coordinator Comments:

• Add media

  Media

• WHS Coordinator Signature:

  Sign

• Site Supervisor Comments:

• Site Supervisor Signature:

  Sign

• General Manager Comments:

• General Manager Signature:

  Sign