INCIDENT/ACCIDENT INVESTIGATION REPORT

• Site

  Select

• Date of investigation

  Date

• Investigation carried out by

• HBP Accident / Near Miss reference number

1.0 PROJECT DETAILS

• Client

  ASDA

  B&Q

  Morrison's

  Other

• Specify Client

• Project name

• Project number

• Site Manager(s)

• Contracts Manager

2.0 DETAILS OF INCIDENT

• What type of incident occurred?

  Select Reportable Accident Minor Accident Dangerous Occurence Property damage Lost time injury Near miss Other incident requiring investigation

  • Reportable Accident
  • Minor Accident
  • Dangerous Occurence
  • Property damage
  • Lost time injury
  • Near miss
  • Other incident requiring investigation

• Date and time of occurrence:

  Date

• Brief Summary (What, where, when, who & emergency measures taken)

• Has anybody been injured?

  YES

  NO

• Name of Injured Person(s):

• Address:

• DOB:

• Employment category

  Select HBP Employee HBP Employee (agency worker) Subcontractor Client Employee Member of Public Other

  • HBP Employee
  • HBP Employee (agency worker)
  • Subcontractor
  • Client Employee
  • Member of Public
  • Other

• undefined

• Role:

• Agency:

• Role

• Company

• Trade

• Type of Injury:

  Cut

  Graze

  Strain/Sprain

  Fracture/break

  Other

• Part(s) affected

  Select Face Head Back Arm Hand Finger Upper leg Lower leg Ankle Foot Torso

  • Face
  • Head
  • Back
  • Arm
  • Hand
  • Finger
  • Upper leg
  • Lower leg
  • Ankle
  • Foot
  • Torso

• State which

• Side of body

  Left

  Right

• Did they require:

  Select First Aid Treatment A&E Hospitalization Walk in centre No treatment required

  • First Aid Treatment
  • A&E
  • Hospitalization
  • Walk in centre
  • No treatment required

• Did the injured person return to work straight after reporting the injury/receiving first aid treatment?

  YES

  NO

• Please state amount of time lost to date

  Yes

  No

  N/A

3.0 REPORTING

• Have Client escalation procedures been followed? Date and method reported

• Was the incident RIDDOR reportable?

  YES

  NO

• Date reported

  Date

• Reporting Reference Number

• Type of RIDDOR?

  7 day +

  Major

  Dangerous occurence

  Fatality

• (*H&S Lead to complete) Date reported to insurers

  Date

• Claim Ref: (if relevant)

4.0 INVESTIGATION

• Exact Location of occurrence, please use diagram/drawing and include photos where appropriate:

  Media

• Please give a detailed description of what happened, attaching any relevant documents or photos

• What task was being performed at the time? What other works were in the vicinity?

• Did anyone else on site affect/influence the accident? If so, please give details

• What equipment was in use, was it in good condition & appropriate for the task?

  Yes

  No

  N/A

• Was the incident related to COSHH substances? If so, please provide details

  Yes

  No

  N/A

• What PPE was being worn, was it in good condition & appropriate for the task?

  Yes

  No

  N/A

• Were there adequate safe working procedures & documentation in place and were they followed?

  Yes

  No

  N/A

• Were the people involved competent and suitable?

  Yes

  No

  N/A
5.0 WITNESSES

• Were there any witnesses?

  YES

  NO

• Name, Company

• Statement taken? If yes, please attach notes/photos/documents

  YES

  NO

6.0 CONCLUSIONS

• Please describe what contributed to the incident, consider the context and both immediate and underlying causes.

7.0 RISK CONTROL ACTION PLAN

• What immediate actions were taken following the incident?

• Add additional follow up actions in this section