Title Page
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Department
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Name of the involved person
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Job title of involved person
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Date and time of the incident
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Location of the incident
DETAILS OF THE INCIDENT
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Describe what activity the involved person was doing at the time of the incident
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Description of the incident
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Name of any witnesses
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Detail any equipment involved in the incident 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
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)
