Information
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Client / Site
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Prepared by
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Conducted on
Section 1
THIS DOCUMENT IS SPLIT INTO 2 SECTIONS. TOOGLE THROUGH THE SECTIONS AT THE BOTTOM OF THE PAGE.
SECTION 1 - Accident/Incident Type
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Select either 'Personal', Event' or 'Near Hit'
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PERSONAL (non work related injury)
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EVENT - Accident/incident resulting in injury, illness, damage or harm.
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NEAR HIT - An incident that had the potential in resulting in injury, illness, damage or harm.
NOTE: For 'Near Hit' complete investigation in relation to potential outcome of incident.
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Report Status
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Revised Status (if revised)
Once both Sections are complete email to safety department to complete further investigation.
Section 2
THIS DOCUMENT IS SPLIT INTO 2 SECTIONS. TOOGLE THROUGH THE SECTIONS AT THE BOTTOM OF THE PAGE.
SECTION 2 - Incident Details
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Date and Time of Accident/Incident
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Date and Time of Investigation Report
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Person(s) Carrying Out Investigation
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Contractor
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Contract Persons' Drivers Licence
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Location of Accident/Incident
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Activity at Time of Accident/Incident
Person(s) Involved
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Full Name of Employee(s)
Employee
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Full Name
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Supervisor
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Safety Advisor/Representative
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Any Witnesses
Witness
What Happened/What Was Observed
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Please only state factual information.
Examples: What is the damage or loss - What was the injured party doing - What had the injured party been instructed to do - What tools were being used - What did the injured/witness see - What safety rules were violated - What safety procedures were in place - What permits were being used - What isolation procedures were in place - What training had been given - What communication system was in place at the time -
Employee Statement Form
Statement
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Statement
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Name and Signature
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Witness
