HSE Managers Accident, Incident or Near Miss Investigation Report

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date
• Location of Accident, Incident or Near Miss
  Address

• Prepared by

• Distrobution

Notification

• Notified by?

• Department / Area?

  Select Head Office HR FM Workshop Tins & Trays Warehouse Transport Clean & Service Admin Clean & Service Technician Reactive Engineering Install Engineers Logistics Project Management

  • Head Office
  • HR
  • FM
  • Workshop
  • Tins & Trays
  • Warehouse
  • Transport
  • Clean & Service Admin
  • Clean & Service Technician
  • Reactive Engineering
  • Install Engineers
  • Logistics
  • Project Management

• Date of notification

  Date

Incident

• Date and Time of Incident?

  Date

• Type of Incident

  Accident

  Incident

  Near Miss

  RIDDOR

• Type of Injury?

• Was first aid treatment required?

  No

  Yes

• Was hospital treatment required?

  No

  Yes

• Pictorial or video of injury of injury, incident or near miss.

  Media

• Did the incident result in lost time, if so how many days?

  No

  Yes

• Description of the Accident, Incident or Near Miss.

Forms

• Has the Accident form been received?

  Yes

  No

• Has the Internal Accident / Incident / Violence Report form been received?

  Yes

  No

Details of Involved Parties

• Name of injured Person

• Department

  Select Head Office HR FM Workshop Tins & Trays Warehouse Transport Clean & Service Admin Clean & Service Technician Reactive Engineering Install Engineers Logistics Project Management

  • Head Office
  • HR
  • FM
  • Workshop
  • Tins & Trays
  • Warehouse
  • Transport
  • Clean & Service Admin
  • Clean & Service Technician
  • Reactive Engineering
  • Install Engineers
  • Logistics
  • Project Management

• Name and details of witnesses?

Other Information Requirements

• Information required for a possible Claim or RIDDOR?

  Select Training Records Qualification Records Job Log Risk Assessments N/A

  • Training Records
  • Qualification Records
  • Job Log Risk Assessments
  • N/A

Actions from the Investigation

• Status?

  Open

  Closed

• HSE Managers Comments?

• Action Taken?

• Date of Conclusion?

  Date

Signature

• HSE Managers Signature.

  Sign