Information
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Conducted on
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Prepared by
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Location
Site details
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Project:
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Location
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Name of person completing this report:
Accident/Incident Details
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Date and time of injury;
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Employee Name
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Relevant Training / Toolbox talk to the task being undertaken
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Job Title:
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Job title if not listed above
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Location of accident (please be specific)
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Nature of Incident or Injury
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Describe who, what, when,where, why and how injury occurred:
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Contributing causes of the Incident: (Inadequate training, Inadequate supervision. Employee not following proper safety procedures and instructions)
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Possible Cause or Causes of the incident: (Inadequate PPE, Not Paying attention to surroundings, failure to utilise safety equipment)
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What is the employee's current status if injured: Describe. ( Returned to work the next day, off of work do to injury, off of work do to restrictions, In hospital, etc.)
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Severity:
- First Aid
- Repotable
- Lost Time
- Restricted Duty
- Fatality
Time line for the accident
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Set out the time line for the incident
Supervision details
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Was a JSA or FLHA completed before work began:
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Safety Department Informed?
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Client (PC) Informed?
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Date and Time when the employer was notified:
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Do we have Light duty work for him based on restrictions?
Injured Party statement
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Name & Signature of the injured party
Witness statements
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Witnesses 1
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Name and signature of the witness 1
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Witnesses 2
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Name and signature of the witness 2
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Witnesses 3
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Name and signature of the witness 3
Injury Details if Applicable
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Where was the Medical treatment first provided?
- Minor Onsite
- A&E Treated/Released
- Hospitalized > 24 hrs
- Hospitalized < 24hrs
- No Medical Treatment
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What type of provider performed treatment?
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If you choose other please specify.
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Provider Doctor Details
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Part of Body injured:
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Will the employee have any restrictions:
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If so, what are they?
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Anyone else injured:
Corrective Actions
Action: Short Term
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What was the immediate action taken to correct the issue (how was this done):
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Who was the responsible party for correcting the issue:
Action: Long Term
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What is the long term action needed to correct the issue:
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Who was the responsible party for correcting the issue:
Additional Information
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Lessons Learned:
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Please provide all attachments that apply: Pictures, Drawings, Training Records, Statement of Employee, Statement of Witness/es, Other.
Investigation Conclusions
Person Completing Form (please sign below)
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Is the above report a true reflection of the Accident / Incident
Supervisor in Charge (please sign below)
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Is the above report a true reflection of the Accident / Incident
Injured Party witnessing the completion of the forms agreement with the content and that it is a true reflection of the accident / Incident
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Is the above report a true reflection of the Accident / Incident