CCL INCIDENT INVESTIGATION REPORT

• Site/Job

• Date and Time of Audit

  Date

• Prepared by

• Location
  Address

1. EVENT DETAILS

• Please click "Add Investigator" button.

Investigator

• Investigator Name

• Date and Time of the Event

  Date

• Date First Reported

  Date

• Date of this Report

  Date

EVENT TYPE AND DEFINITION

• Hazard Report (no incident reported, complete report Follow-up)

• Near Miss (any event/observation that could have resulted in injury or property damage)

• Minor Harm Accident (Onsite First Aid treatment / potential future harm)

• Harm Accident (Off site medical treatment and rehabilitation/ rest for not serious or permanent injury)

• Serious Harm Injury (as defined by the act – refer to your policy before ticking)

• Damage to Machinery / Property Plant / Equipment / Property Damaged Details

• Has Work safe been notified?

  Yes

  No

  Not Required

• What is a notifiable incident?

2. INVOLVED PERSONS

• Please click "Add Name" button.

Name

• Name of Injured / Near Miss Person

• Employer

  CCL x Contractor

  Public / Visitor

  Other

• Please Specify

• Name of Witness / Witnesses and Contact Phone Number(s)

• Brief Summary of Event and Findings

• Describe the Event

• How was this allowed to happen within our company? (what processes were broken, safeguards non-existent, etc that allowed this to happen on our watch? List all that apply)

• Training – Competency / Formal

• Risk Assessments and Documentation

• Equipment Involved

• Process Failure

• 

• How Serious could this have been?

  Insignificant

  Minor

  Moderate

  Major

  Catastrophic

• The likelihood of such an event reoccurring

  Rare

  Unlikely

  Possible

  Likely

  Almost Certain

• If the event did reoccur, the likely consequence would be

  Insignificant

  Minor

  Moderate

  Major

  Catastrophic

• The risk score is therefore

  Select Rare | Insignificant Rare | Minor Rare | Moderate Rare | Major Rare | Catastrophic Unlikely | Insignificant Unlikely | Minor Unlikely | Moderate Unlikely | Major Unlikely | Catastrophic Possible | Insignificant Possible | Minor Possible | Moderate Possible | Major Possible | Catastrophic Likely | Insignificant Likely | Minor Likely | Moderate Likely | Major Likely | Catastrophic Almost Certain | Insignificant Almost Certain | Minor Almost Certain | Moderate Almost Certain | Major Almost Certain | Catastrophic

  • Rare | Insignificant
  • Rare | Minor
  • Rare | Moderate
  • Rare | Major
  • Rare | Catastrophic
  • Unlikely | Insignificant
  • Unlikely | Minor
  • Unlikely | Moderate
  • Unlikely | Major
  • Unlikely | Catastrophic
  • Possible | Insignificant
  • Possible | Minor
  • Possible | Moderate
  • Possible | Major
  • Possible | Catastrophic
  • Likely | Insignificant
  • Likely | Minor
  • Likely | Moderate
  • Likely | Major
  • Likely | Catastrophic
  • Almost Certain | Insignificant
  • Almost Certain | Minor
  • Almost Certain | Moderate
  • Almost Certain | Major
  • Almost Certain | Catastrophic

3. TREATMENT AND FOLLOW-UP

• What was the resulting injury?

• What treatment was given to immediately address the issue?

  No treatment given

  Doctor / Hospital

  Onsite first aid

• Attach doctors/hospital report

  Media

• What are the items used?

4. RESULTING ACTIONS

• What can we do better to eliminate/minimize such an event reoccurring?

• Tick items already actioned

  ✔

  ✖

  N/A

• Completed by Name and Signature

  Sign

• Date and Time of Completion

  Date

• Include training and consider feedback from the investigation process in planning actions

  ✔

  ✖

  N/A

• Completed by Name and Signature

  Sign

• Date and Time of Completion

  Date

• Refer to your policy to check if incident needs to be reported to Work Safe

  ✔

  ✖

  N/A

• Completed by Name and Signature

  Sign

• Date and Time of Completion

  Date

5. SUPPORTING MEDIA, DOCUMENTATION AND REPORTS

• Please click "Add Item" button.

Item

• Please Specify the item

• Please put your comments here

• Please upload a photo of the item

  Media

COMPLETION AND SIGN-OFF

• Investigators Review and Sign-Off

• Please click "Add Investigator" button.

Investigator

• Investigator Name and Signature

  Sign

• Management Review and Sign Off

• Manager Name and Signature

  Sign