GIG ACCIDENT / INCIDENT REPORT

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

SECTION 1 REPORT

About the Incident

• When it occured

  Date
• Where it occured
  Address

• Brief description of how incident occurred

• Image of incident

  Media

Was any body injured

• Was anybody injured

  No

  Yes

• If yes

Person

• Name

• Occupation

• Contact telephone number

• Company address

• Extent of Injuries Incurred

• First Aid attention required

  Yes

  No

  N/A

• Section 1 - Is to be sent to the head office within 12 hours when an accident has occurred that is reportable under the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013. The report should be faxed or emailed to the Director responsible for safety immediately.

SECTION 2 - POST ACCIDENT DETAILS

Person filling out this form

• Name

• Contact telephone number

• Position

Treatment

• Describe treatment provided to any injuries resulting from and accident

Review of Working Methology

• Brief description, if relevant, of action implemented following incident / accident occurring

• Has risk been re-assessed

  Yes

  No

  N/A

• Have control measures been revised

  Yes

  No

  N/A

• Describe activities used to implement revised working method e.g Toolbox talks, training etc.
  

Rehabilitation

• Has the injured party return to work

  Yes

  No

  N/A

• If yes

Person

• When did injured party return to work ?

  Date

• Did they resume with the same duties ?

  Yes

  No

  N/A

• Same location

  Yes

  No

  N/A

• Is continued treatment required

  Yes

  No

  N/A

SIGNATURES

• Following satisfactory implementation of the new control measures, the Directors responsible for safety must close out this form

  Sign

• Close out date

  Date