Title Page
-
Conducted on
-
Prepared by
-
Location
-
Incident Type
Incident Report
-
Date & Time of Incident
-
Location of Incident
-
H&S Sub-Type
- Acts of Violence
- COSHH Substances Incident
- Electrical Incident
- Environmental Incident
- Falls/Falling Objects Incident
- Fire Incident
- First-Aid Incident
- Machinery Incident
- Manual Handling Incident
- Medical Treatment Incident
- Missing H&S Incident
- People Movement Incident
- Portable Tools Incident
- Specific Agents Incident
- Substances Misuse
- Transmissible Diseases Incident
- Vehicle Movement Incident
- Visual/Audio Warning Incident
- Work Environment & Welfare Incident
- Other
-
Injury?
-
Name and Company of Casualty
-
Details of Injury Severity & Treatment Given
-
Reportable? (Under RIDDO 2013 Regulations)
-
Details of the Incident (include pictures where possible)
-
Description of Events Causing the Incident
-
Details of any Equipment/Substances Involved
-
Details of any Losses or Damages Caused
-
List Immediate Causes
-
Root Cause
- Controls Not Implemented
- Deliberate Act
- Inappropriate Controls
- Inappropriate MRI Program
- Installation/Fabrication Issue
- Missing MRI Program
- No Controls in Place
- Training Level LTA
- Work Group Communication LTA
- Workplace Design Problem
- Other
- Intervention
- Sickness/Illness
- Unsafe Act
- Unsafe Work Conditions
-
Steps Taken to Prevent Recurrence
-
Timeline of Actions Planned/Taken
