Title Page
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Document Number
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Type of Investigation
- Accident
- Near Miss
- Property Damage
- Dangerous Occurance
- Complaint
- Other
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Brief Details
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Job Number
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Job Name
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Address
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Conducted on
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Prepared by
Details
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Description of the incident
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Date
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Time
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Was this within normal working hours
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Names of staff involved
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Names of any other parties involved
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Was anybody injured
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Name of person injured
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Position
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Employment type
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Address:
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Details of injury
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Did the person carry on working
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Did the person go to hospital
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Which hospital
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Treatment given
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Did the person return to work after treatment
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Where did they go after treatment
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Name of 1st Aider attending
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Accident book number
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Other information
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Was the person carrying out normal working duties
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Details
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Was the task being undertaken in accordance with the procedure / method of work and risk assessments
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Details
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Did the person have the correct training for the task
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What training should they have received
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Was PPE required for the task
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Was the person wearing the correct PPE
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Could this have been avoided
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How could this have been avoided
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If, after considering the evidence, it is felt that this incident does not require further investigation, provide a brief explanation and sign off complete
- No further investigation required
- Further investigation required
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Details of why no further investigation required
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Signed
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Date and Time
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Did anyone witness the incident
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have statements been taken
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Description of area of incident
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Should the person have been on the premises
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Floor Conditions
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Details
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Lighting levels
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Atmosphere
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Details
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Is CCTV availble
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Is there photographic evidence
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Was any equipment involved
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What equipment was used
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Was the equipment correct for the task
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Was the person correctly trained
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Did the equipment have the correct pre-use, safety checks & statutory inspections
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Did anyone witness the incident
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have statements been taken
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Witnesses
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Incident drawing
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Summary of findings
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Recommendations to action
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Who should action these recommendations
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When should these be actioned by
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Signed
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Date
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Comments
