Title Page
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Department
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Name of injured person
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Job title of injured person
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Date and time of the accident
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Location of the accident
DETAILS OF THE ACCIDENT
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Describe with at much detail as possible, what activity the injured person was doing at the time of the accident
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Describe the injuries caused
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How did the injury occur and has a cause been identified?
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Were any emergency measures taken? ie hospital/first aid/works stopped immediately
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Name of any witnesses
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Detail any equipment involved in the accident including ID number
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Are there adequate safe working procedures in place e.g. Standard Operating Procedures, COSHH (attached document or detail what document is saved as evidence)
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What PPE was being used at the time of the incident
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Was the injured person competent in carrying out the activity? Detail any training provided.
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Describe the environmental conditions
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Is the injured person absent from work due to the event? (If yes add action to Health and Safety Advisor with details of the absence/fit note details)
RECOMMENDATIONS
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Detail recommendations to reduce risks or remove hazard
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Name of supervisor/manager
SIGN OFF
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Initial investigation/report completed by
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Date
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Signed
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Further investigation required (complete action details if Yes)
