• Location

  • Investigation Ref No #:

  • Date of occurrence

  • Date reported

Type of Incident. Select all that apply.

  • Near Miss

  • First Aid

  • Medical Aid

  • Restricted Work

  • Lost Time Injury

  • Occupational Illness

  • Fire or Explosion

  • Equipment Failure

  • Property Damage

  • Material or Business Loss

  • Motor Vehicle Accident

  • Threats

  • Other

Injury

  • What type of injury?

  • What body part was injured?

  • Was follow-up treatment required?

  • If incident was reported to RIDDOR, state reference:

Person Involved

  • Persons name

  • Date of Birth

  • Address

  • Department

  • Contact details

Description

  • Clearly describe how the incident occurred.

  • Add media

Witnesses

  • Include the names and phone numbers of any witnesses to the incident. Attach witness statements or cross refer to statements.

Analysis

  • Immediate causes; what acts and/or conditions contributed directly to this accident?

  • Basic causes; what are the contributing factors? (Job factors, personal factors)

Prevention

  • What action or recommendations are required to be made to prevent recurrence?

  • When are actions or recommendations required to be implemented by?

Frequency Potential

  • Frequent

  • Probable

  • Occasional

  • Remote

  • Improbable

Severity

  • Catastophic

  • Critical

  • Moderate

  • Minor

Costs (if applicable).

  • Estimated:

  • Actual:

Conclusion

  • Action required:

  • Investigated by:

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