Title Page
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Document No.
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Prepared By:
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Conducted On:
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Location:
Initial Event Details
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Event Type
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Accident Type
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RIDDOR Ref:
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RIDDOR Ref:
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RIDDOR Ref:
Injured Party Details:
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Name:
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Age:
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Address:
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Telephone:
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Status:
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Length of Employment:
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Time Into Shift:
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Occupation:
Accident / Injury Details:
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Date & Time of Accident:
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Location of Accident:
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Type of injury:
- Amputation
- Bruising
- Burn/scald
- Chemical reaction
- Dislocation
- Foreign body
- Fracture
- Internal
- Laceration/cut
- Scratch/abrasion
- Soft Tissue
- Strain/sprain
- Other
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Specify Body Part Injured:
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Type of Treatment Given:
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Name of First Aider:
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Type of First Aid Treatment Given:
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Hospital Name:
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Hospital Address:
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Treatment Given:
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Duration of Hospital Stay:
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Pictures of Accident Scene & Injury:
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Description of How The Accident / Injury Occured:
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Immediate Remedial Actions Taken:
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Injured Party Statement:
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Were There Any witnesses:
Witness Details:
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Name:
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Address:
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Telephone:
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Witness Statement:
Investigation:
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Type of Accident:
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Causal Analysis:
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Life Saving Rule:
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Investigation Findings:
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Lessons Learned:
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Supporting Documents
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Type of Environmental Event
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Security Event Type
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Observation Type
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Type of Property Loss or Damage:
Vehicle Driver Details:
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Name:
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Age:
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Address:
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Telephone:
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Status:
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Length of Employment:
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Time Into Shift:
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Occupation:
Vehicle Damage Details:
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Date & Time of Damage:
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Location Damage Took Place:
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Description of How The Damage Occurred:
Damaged Vehicle:
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Vehicle Type:
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Vehicle Registration:
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Description of Damage:
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Photos of Damage
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Statements:
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Were There Any witnesses:
Witness Details:
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Name:
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Address:
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Telephone:
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Witness Statement:
Property Owner Details:
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Name:
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Age:
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Address:
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Telephone:
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Status:
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Length of Employment:
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Time Into Shift:
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Occupation:
Property Damage Details:
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Date & Time of Damage:
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Location Damage Took Place:
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Description of How The Damage Occurred: (Include Photos)
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Statement From Property Owner:
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Were There Any witnesses:
Witness Details:
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Name:
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Address:
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Telephone:
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Witness Statement:
Investigation:
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Causal Analysis:
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Investigation Findings:
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Lessons Learned:
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Supporting Documents
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Near Miss Location:
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Date & Time of Near Miss:
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Description of Near Miss:
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Were There Any witnesses:
Witness Details:
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Name:
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Address:
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Telephone:
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Witness Statement:
Investigation:
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Causal Analysis:
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Investigation Findings:
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Lessons Learned:
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Supporting Documents
Sign Off
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Investigators Signature:
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SHE Supervisor Sign-Off:
