FSG Incident/Accident Investigation Template

FSG Accident and Incident Investigation

Investigation Details

• Who will be leading this investigation?

• Who will assist in this investigation

• Please enter the date of this investigation.

  Date

• What kind of incident are you investigating?

  Injury/Harm

  Property Damage

  Near-Miss

Incident Details

• Name of Injured/Involved person (if any)

• Address
  Address

• When did the incident occur

  Date

• Who was involved/ injured

  Employee

  Visitor

  Contractor

  Truck Driver

• What type of injury is it

  Select Crush/Impact Strain/Sprain Fracture/Break Cut/Laceration Dislocation Foreign Body Penetration Bruising Scratch/Abrasion Amputation Burn/Scald Internal Injury Allergic Reaction Other

  • Crush/Impact
  • Strain/Sprain
  • Fracture/Break
  • Cut/Laceration
  • Dislocation
  • Foreign Body
  • Penetration
  • Bruising
  • Scratch/Abrasion
  • Amputation
  • Burn/Scald
  • Internal Injury
  • Allergic Reaction
  • Other

• Describe in detail any injury sustained, if no injury, describe any damaged equipment, plant or machinery etc

• Injury Severity Rating

  Minor

  Moderate

  Notifiable Injury

• Worksafe Notified

  Yes

  No

  N/A

• Give details of any tasks being carried out at the time of the incident/injury?

• Have all persons involved in the incident received information, instruction and training for the tasks relating to the incident?

• Describe in detail what happened?

• Outcome

  Return to work

  Alternative/Light Duties

  Time Off

• Do you think any persons involved in the incident were acting dangerous/ negligent in any way, if yes, describe how.

• Please add as many images as you can that relate to the incident.

  Media

• List all witnesses of the incident

Medical Treatment

• Was First Aid administered on-site

  Yes

  No

• Describe what assistance was provided by the First Aider, list any medical equipment used (plasters, bandage, eyewash etc.)

• Did the injured person require any further treatment?

  Select A&E Urgent Care Gp Visit Emergency Response (111 or Emergency Services)

  • A&E
  • Urgent Care
  • Gp Visit
  • Emergency Response (111 or Emergency Services)

• What was the outcome of this?

• Please provide dates and times

  Date

Witness Statement 1

• Please interview all witnesses and ask for signatures

• Name

• Address
  Address

• I confirm that the information I have provided in relation to this incident is accurate.

  Sign

• Select date

  Date

Witness Statement 2

• Please interview all witnesses and ask for signatures

• Name

• Address
  Address

• I confirm that the information I have provided in relation to this incident is accurate.

  Sign

• Select date

  Date

How did the incident/injury occur?

• Please list the main cause or causes of this incident or injury

• Please list any contributing factor or factors relating to this incident or injury

  Select Failure to wear PPE Inadequate Training Improper behaviour Poor Housekeeping Other

  • Failure to wear PPE
  • Inadequate Training
  • Improper behaviour
  • Poor Housekeeping
  • Other

• Describe in detail your findings as to how the incident has occurred?

Corrective and Preventive Action

• What corrective actions have been taken immediately?

• Who carried out the corrective actions?

  Sign

• Describe what actions can be taken to prevent a recurrence of this incident (Improved training, PPE, improved maintenance etc)

Incident Reporting

• Did the injured person require time off work

  Yes

  No

• Is this incident reportable under the HSWA Act 2015 (see Worksafe Notifiable Events)

  Yes

  No

• Report now or check if reportable at the Worksafe site online
  http://www.worksafe.govt.nz

Results of Investigation

• Explain the results of your findings, take into account all factors and provide a balanced view, if there is a clear cause for the incident, be sure to list it.

• If any equipment, plant, machinery have been damaged please list and describe the issues

Authorisation

• I agree that all information provided by this investigation is accurate.

• Signed by injured person

  Sign

• Signed by Lead Investigator

  Sign

• Signed by Assistant Investigator

  Sign

• Signed by Assistant Investigator

  Sign