Glenevin - Event Investigation

• Document No.

• Prepared By:

• Conducted On:

  Date
• Location:
  Address

• Event Type

  Select

• Incident Type

  Select

Lost Time

• Weeks

  Yes

  No

  N/A

• Days

  Yes

  No

  N/A

• Hours

  Yes

  No

  N/A

Injured Party Details:

• Is there an injured party involved

  Yes

  No

  N/A

• Name

• Age

• Address

• Telephone Number:

• Injured Party Status

  Select

• Status details:

  Select

• Length of Presence On Site/On Project

• Time Into Shift:

• Occupation:

undefined

Incident / Injury Details:

• Date & Time of Incident:

  Date

• Date & Time of Incident reporting:

  Date

• Location of Incident:

• Type of injury:

  Select Amputation Bruising Burn/scald Chemical Burn Dislocation Contact With Foreign Item Fracture Internal injury Laceration/cut Scratch/abrasion Soft Tissue Injury Strain/sprain Other

  • Amputation
  • Bruising
  • Burn/scald
  • Chemical Burn
  • Dislocation
  • Contact With Foreign Item
  • Fracture
  • Internal injury
  • Laceration/cut
  • Scratch/abrasion
  • Soft Tissue Injury
  • Strain/sprain
  • Other

• Specify Body Part Injured and Nature of Injury

• Type of Treatment Given/Has first Aid Been Applied

• Pictures of Incident Scene & Injury:

  Media

• Has the Accident Book Been Filled Out And By Who

• Description of How The Incident Occurred. (Please include Details Of The Events Leading Up To The Incident in The Form of A Timeline)

• Immediate Remedial Actions Taken (Please include details of names, dates, times etc as appropriate)

• Injured Party Statement if appropriate

• Were There Any witnesses:

  Yes

  No
Witness Details:

• Name:

• Address:

• Telephone:

• Witness Statement (please add details of relation to Glenevin. Please include Details Of The Events Leading Up To The Incident in The Form of A Timeline)

Investigation:

• Investigation Findings (factual)

• Causal Analysis:

• Immediate Cause

• Underlying and Contributing Cause

• Root Cause

• Relevant Life Saving Rule:

• Lessons Learned:

• Preventative Measures Recommendations (please detail objective actions with time frames for relevant individuals)

Supporting Documents

• Is relevant policy/procedure in place and reviewed by relevant employee

  Yes

  No

  N/A

• Does relevant Policy/Procedure Require Further Review and Amendment

  Yes

  No

  N/A

• Are relevant Risk Assessments and Method Statements in place and reviewed by individuals

  Yes

  No

  N/A

• Does the Relevant Risk Assessment and Method Statement require Review and Amendment

  Yes

  No

  N/A

• 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

• Is Relevant Safe System Of Works in Place and Followed

  Yes

  No

  N/A

• Does Relevant Safe System Of Works Require Amenment

  Yes

  No

  N/A

• Any Other Findings and Recommendations

Distribution of Investigation Report

• Current Report to Be Shared With

  Select SHEQ Director Operations Director Department Manager Supervisor Client (please check confidentiality status) Sub-Contractor (please check confidentiality status) Any Other Party (please check confidentiality status)

  • SHEQ Director
  • Operations Director
  • Department Manager
  • Supervisor
  • Client (please check confidentiality status)
  • Sub-Contractor (please check confidentiality status)
  • Any Other Party (please check confidentiality status)

• Investigators Signature:

  Sign

• What is Your Current Role

• Authorization Sign Off

  Sign

• What Is Your Current Role

• Additional Sign Off As Appropriate

  Yes

  No

  N/A

• What is your Current Role

• Name and Sign

  Sign

• Date

  Date