Title Page

  • Document No.

  • Audit Title

  • Client / Site

  • Conducted on

  • Location of Accident, Incident or Near Miss
  • Prepared by

  • Distrobution


  • Notified by?

  • Department / Area?

  • Date of notification


  • Date and Time of Incident?

  • Type of Incident

  • Was first aid treatment required?

  • Was hospital treatment required?

  • Type of Injury?

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

  • Description of the Accident, Incident or Near Miss.


  • Has the Accident form been received?

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

Details of Involved Parties

  • Name of Employees Involved?

  • Name and details of witnesses?

Other Information Requirements

  • Information required for a possible Claim or RIDDOR?

Actions from the Investigation

  • HSE Managers Comments?

  • Action Taken?

  • Status?

  • Date of Conclusion?


  • HSE Managers Signature.

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.