GCL - Event Investigation - duplicate

• Document No.

• Prepared By:

• Conducted On:

  Date
• Location:
  Address

• Event Type

  Select

• Accident Type

  Select

• RIDDOR Ref:

• RIDDOR Ref:

• RIDDOR Ref:

Injured Party Details:

• Name:

• Age:

• Address:

• Telephone:

• Status:

  Select

• Length of Employment:

• Time Into Shift:

• Occupation:

Accident / Injury Details:

• Date & Time of Accident:

  Date

• Location of Accident:

• Type of injury:

  Select Amputation Bruising Burn/scald Chemical reaction Dislocation Foreign body Fracture Internal Laceration/cut Scratch/abrasion Soft Tissue Strain/sprain Other

  • Amputation
  • Bruising
  • Burn/scald
  • Chemical reaction
  • Dislocation
  • Foreign body
  • Fracture
  • Internal
  • Laceration/cut
  • Scratch/abrasion
  • Soft Tissue
  • Strain/sprain
  • Other

• Specify Body Part Injured:

• Type of Treatment Given:

  Select

• Name of First Aider:

• Type of First Aid Treatment Given:

• Hospital Name:

• Hospital Address:

• Treatment Given:

• Duration of Hospital Stay:

• Pictures of Accident Scene & Injury:

  Media

• Description of How The Accident / Injury Occured:

• Immediate Remedial Actions Taken:

• Injured Party Statement:

  Media

• Were There Any witnesses:

  Yes

  No
Witness Details:

• Name:

• Address:

• Telephone:

• Witness Statement:

  Media

Investigation:

• Type of Accident:

  Select

• Causal Analysis:

• Life Saving Rule:

  Select

• Investigation Findings:

• Lessons Learned:

• Supporting Documents

  Media

• Type of Environmental Event

  Select

• Security Event Type

  Select

• Observation Type

  Select

• Type of Property Loss or Damage:

  Select
Vehicle Driver Details:

• Name:

• Age:

• Address:

• Telephone:

• Status:

  Select

• Length of Employment:

• Time Into Shift:

• Occupation:

Vehicle Damage Details:

• Date & Time of Damage:

  Date

• Location Damage Took Place:

• Description of How The Damage Occurred:

Damaged Vehicle:

• Vehicle Type:

• Vehicle Registration:

• Description of Damage:

• Photos of Damage

  Media

• Statements:

  Media

• Were There Any witnesses:

  Yes

  No
Witness Details:

• Name:

• Address:

• Telephone:

• Witness Statement:

  Media

Property Owner Details:

• Name:

• Age:

• Address:

• Telephone:

• Status:

  Select

• Length of Employment:

• Time Into Shift:

• Occupation:

Property Damage Details:

• Date & Time of Damage:

  Date

• Location Damage Took Place:

• Description of How The Damage Occurred: (Include Photos)

• Statement From Property Owner:

  Media

• Were There Any witnesses:

  Yes

  No
Witness Details:

• Name:

• Address:

• Telephone:

• Witness Statement:

  Media

Investigation:

• Causal Analysis:

• Investigation Findings:

• Lessons Learned:

• Supporting Documents

  Media

• Near Miss Location:

• Date & Time of Near Miss:

  Date

• Description of Near Miss:

• Were There Any witnesses:

  Yes

  No
Witness Details:

• Name:

• Address:

• Telephone:

• Witness Statement:

  Media

Investigation:

• Causal Analysis:

• Investigation Findings:

• Lessons Learned:

• Supporting Documents

  Media

• Investigators Signature:

  Sign

• SHE Supervisor Sign-Off:

  Sign