Information

  • Document No.

  • Audit Title

  • Client / Site

  • Image of site

  • Investigation Started on

  • Prepared by

Executive summary

Executive summary

  • Background

  • Conclusions drawn

  • cost to the organisation

  • Recommendations

  • Method of investigation

Part 1 to be completed immediately upon notification

Part 1 - to be completed immediately upon notification

  • Initial report made by

  • Date of incident if known

  • Time of incident if known

  • Incident

  • Ill health

  • Minor injury

  • Serious injury

  • Fatality

  • Near miss

  • Number of casualties

  • Date initial report was received by corporate and public safety

Part 2 - initial assessment

  • Tap to enter information

Part 2 initial assessment be carried out by the person responsible for health and safety

  • Types of incident

  • Potential for harm

  • Is the incident reportable under RIDDOR

  • Tap to enter information
  • Date and time reported and report number

  • Copy of report

  • Incident report completed ? Date entered / reference number

  • Level of investigation carried out by line manager

  • Name of line manager?

  • Is a further investigation required?

  • Priority of investigation? ( 1 is low 5 is high)

  • Names of people required during the further investigation

Part 3- investigation and information gathering

Part 3 investigation and information gathering

  • 1. Where did the incident take place
  • Site photo

  • 2. Names of the injured person and extent of injuries or ill health including the type and location of any injury

  • 3. Brief description of how the incident occurred

  • 4. What work activities would be carried out at the time?

  • 5. Was there anything unusual about the work conditions at the time?

  • 6. Is there a risk assessment available for the activity?

  • 7. Is there an adequate safe working procedure available?( or method statement)

  • Tap to enter information
  • 7a. Was it followed?

  • Tap to enter information
  • 7a. Why not?

  • 8. Was the risk known ?

  • Tap to enter information
  • 8a. Why was it not controlled?

  • Tap to enter information
  • 8a. Why was the risk not foreseen

  • 9. Did the organisation and arrangement of the work influence the adverse effect?

  • 10. Was maintenance and cleaning sufficient?

  • 11. Weather people involved to be considered a competent and suitable?

  • 12. Did the workplace layout influence the adverse event?

  • 13. Did the nature or shape of the materials or substance influence the adverse event?

  • 14. Did any machinery or equipment influence the adverse effect?

  • 15. Was safety equipment sufficient?

  • 16. Was PPE required?

  • Tap to enter information
  • 16a. Was it issued?

  • 16b. Was it warm and used correctly?

  • 17. did other conditions influence the adverse event?

Part 3a - evidence and statements

Part 3a evidence and statements

Physical evidence

  • Has any physical evidence been seized or recovered?

  • Tap to enter information Physical evidence
  • Description of evidence seized or recovered

  • Photographs of evidence seized or recovered

  • Have any witness statements been taken?

  • Tap to enter information Witness statements
  • Name of witness

  • Date statement received

  • Notes

  • Statement

  • Other previously not included photographic or document evidence

Part 4 - legislation and legal risks

Part 4 legislation and legal risks

    Legislation
  • Tap to enter information

  • Detail

  • Could this have been breached?

  • Other risks to the council and its officers
  • Description and nature of the risk including maximum penalty if applicable

  • Is this risk to council officers or the corporate body

Part 5 - analysis

Part 5 analysis

    Current controls
  • Current control measures in place and was it followed?

  • Root cause analysis diagram

  • Immediate cause

  • Underlying causes

  • Root causes

  • Are there similar risks elsewhere?

  • Have similar incident happened before?

  • cost of this incident to the organisation

  • Total cost of this incident so far

Part 6 recommendations

    Tap to enter information

Part 6 - recommendations

  • Does the risk assessment require amending?

  • Tap to enter information
  • Name of responsible officer

  • Target date

  • Does any method statement require amendment

  • Tap to enter information
  • Name of responsible officer

  • Target date

Other recommendations

    Controls
  • Control measure or recommendation

  • Target date

  • Controls
    description
    responsible person

Part 7 - end of report

Part 7 end of report

  • Signed on behalf of the investigation team

  • Position

  • Members of the investigation team

  • Distribution List name and position

  • List of appendices

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.