Investigation details

  • Incident type

  • Description

  • Is someone involved (Injured)

  • Name

  • Address

  • Date of birth

  • Job title

  • Company employed by

  • Was there any injury

  • Details of injury

  • Treatment

  • Did the injured person work after incident

  • Time lost (hours/days)

  • Description of incident (include what,where,when,who and emergency measures taken)

  • Weather conditions

  • Was PPE worn

  • List PPE

  • Is there plant or equipment involved

  • Details of plant and equipment

  • Was the person competent in the use of plant

  • Is there any certification or licenses required for plant

  • See attached

Supplementary information

  • Do you have RAMS,INDUCTIONS,TBT or Permits

  • RAMS

  • Induction record

  • Relevant TBT

  • Permits if required

Witnesses

  • Do you have a witness

  • Name

  • Address

  • Job title

  • Employee

  • Statement

  • Signature

Corrective and preventive actions

  • Corrective action 1

  • Control measure

  • To be implemented by

  • Action on

  • Corrective action 2

  • Control measure

  • Select date

  • Action on

  • Corrective action 3

  • Control measure

  • Select date

  • Action on

  • Corrective action 4

  • Control measure

  • Select date

  • Action on

  • Corrective action 5

  • Control measure

  • Select date

  • Action on

  • Any further required measures or information

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