Incident / Accident Investigation Report

• Audit Title:

• Document No.:

• Campus / department:

• Conducted on:

  Date

• Prepared by:

• Location:
  Address

• Personnel as witnesses:

• Personnel as Subject experts:

• Location

• Investigation Ref No #:

• Date of occurrence

  Date

• Date reported

  Date

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?

  Yes

  No

  N/A

• If incident was reported to RIDDOR, state reference:

Person Involved

• Select Staff Student Visitor Contractor

  • Staff
  • Student
  • Visitor
  • Contractor

• Persons name

• Date of Birth

• Address

• Department

• Contact details

Description

• Clearly describe how the incident occurred.

• Add media

  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:

  Sign