Title Page
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Document No.
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Audit Title
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Client / Site
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Conducted on
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Location of Accident, Incident or Near Miss
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Prepared by
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Distrobution
Notification
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Notified by?
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Department / Area?
- HR
- J2 Workshop
- J2 Warehouse
- Head Office
- Transport
- Clean & Service
- Reactive Engineering
- Install Engineers
- FM
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Date of notification
Incident
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Date and Time of Incident?
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Type of Incident
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Was first aid treatment required?
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Was hospital treatment required?
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Type of Injury?
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Did the incident result in lost time, if so how many days?
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Description of the Accident, Incident or Near Miss.
Forms
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Has the Accident form been received?
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Has the Internal Accident / Incident / Violence Report form been received?
Details of Involved Parties
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Name of Employees Involved?
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Name and details of witnesses?
Other Information Requirements
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Information required for a possible Claim or RIDDOR?
- Training Records
- Qualification Records
- Job Log Risk Assessments
- N/A
Actions from the Investigation
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HSE Managers Comments?
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Action Taken?
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Status?
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Date of Conclusion?
Signature
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HSE Managers Signature.