Incident and investigation form

• Site conducted

  Select

• Conducted on

  Date

• Prepared by

• Reference number

• Incident Summary

Incident Category:

• Which type of Incident do you want to report?

  Incident

  Near Miss

  Enforcement visit

Time and Location Details

• Who was involved?

  Select Member or Guest Employee on shift Employee off shift Contractor

  • Member or Guest
  • Employee on shift
  • Employee off shift
  • Contractor

• Was any first aid given?

  Yes

  No

• Please specify first aid given

• What was the incident type?

  Personal Injury

  Illness

  Damage

• How many people were injured?

• What was the injury type?

• Was the injured person(s) taken to the hospital directly from the club?

  Yes

  No

  Don't know

• Which Hospital?

• What was the illness type?

• What was the damage type?

• When was the incident occur?

  Date

• What were the light conditions?

  Too dark

  Adequate

  Too bright

• What were the weather conditions?

  Select Sunny Dry Overcast Raining Snowing Windy

  • Sunny
  • Dry
  • Overcast
  • Raining
  • Snowing
  • Windy

• What were the surface conditions?

  Select Adequate Slippery Uneven Smooth

  • Adequate
  • Slippery
  • Uneven
  • Smooth

• Where was the incident in the facility?

  Select Swimming Pool Tennis Court (outdoor) Indoor Court Gym Spa Car Park Other

  • Swimming Pool
  • Tennis Court (outdoor)
  • Indoor Court
  • Gym
  • Spa
  • Car Park
  • Other

Incident details

• Provide details of the incident

• Is CCTV footage and images available?

  Yes

  No

• Include link or video to CCTV footage and any images of the area

• Could this near miss result in an insurance claim?

  Yes

  No

• Has insurance company been informed?

  Yes

  No

• Which insurance company?

• Were the police notified?

  Yes

  No

• Who notified the police?

• What was the police officers name?

• Which police station?

• What is the crime reference number?

• Was the property occupied at the time?

  Yes

  No

• How was access gained?

  Key

  Swipe card

  Break-in

• Was any damage caused?

  Yes

  No

• What damage was caused?

• Was the incident witnessed?

  Yes

  No

• Who witnessed the incident? (include/ attach statements)

Follow Up

• What immediate action has been taken to prevent reoccurrence?

• Did the incident occur due to a workplace process or activity?

  Yes

  No

• Did the incident occur directly due to a sport?

  Yes

  No

• Was the club made aware of the incident at the time?

  Yes

  No

• Damage Breakdown

  Select Window Fire Door Alarm Fixtures/ Fittings CCTV Other

  • Window
  • Fire Door
  • Alarm
  • Fixtures/ Fittings
  • CCTV
  • Other

Cost Breakdown

• Cash (£)

• Stock (£)

• Damage (£)

• Other (£)

• Total (£)

Time and Location Details

• Who was involved?

  Select Member or Guest Employee on shift Employee off shift Contractor

  • Member or Guest
  • Employee on shift
  • Employee off shift
  • Contractor

• When was the near miss identified?

  Date

• What were the light conditions?

  Too dark

  Adequate

  Too bright

• What were the weather conditions?

  Select Sunny Dry Overcast Raining Snowing Windy

  • Sunny
  • Dry
  • Overcast
  • Raining
  • Snowing
  • Windy

• What were the surface conditions?

  Select Adequate Slippery Uneven Smooth

  • Adequate
  • Slippery
  • Uneven
  • Smooth

• Where was the near miss?

  Select Swimming Pool Tennis Court (outdoor) Indoor Court Gym Spa Car Park Other

  • Swimming Pool
  • Tennis Court (outdoor)
  • Indoor Court
  • Gym
  • Spa
  • Car Park
  • Other

Near miss details

• Provide details of the near miss

• Is CCTV footage and images available?

  Yes

  No

• Include link or video to CCTV footage and any images of the area

• Could this near miss result in an insurance claim?

  Yes

  No

Follow Up

• What immediate action has been taken to prevent reoccurrence?

• Did the incident occur due to a workplace process or activity?

  Yes

  No

• Did the incident occur directly due to a sport?

  Yes

  No

• Was the club made aware of the incident at the time?

  Yes

  No

Visit Details

• What type of enforcement visit

  Food Standards

  Fire

  Health and Safety

  Trading Standards

  Other

• Name and contact details of enforcement officer

• Name of authority

• When was the enforcement visit?

  Date

• What was the reason for the visit?

  Routine

  Accident/ Incident follow up

• What was discussed?

Follow Up

• Are any actions required to address any raised concerns?

  Yes

  No

Sign Off

• Name and signature of person reporting

  Sign

Investigation Team

• Team leader

Team Members

• Name of Team member

Interim Containment

• Describe what has been put in place to stop the issue from escalating?

  Select Human factors Materials Measurement Equipment Process Environment

  • Human factors
  • Materials
  • Measurement
  • Equipment
  • Process
  • Environment

• What corrective actions have been implemented to improve the human factor cause of this accident?

  Select Lessons Learnt communicated Re-trianing Other

  • Lessons Learnt communicated
  • Re-trianing
  • Other

• Please describe the action implemented

• Has this action been completed?

  Yes

  No

• Has this action been completed?

  Yes

  No

• Has this action been completed?

  Yes

  No

• What corrective actions have been implemented to improve the materials used in this accident?

  Select New supplier Improved materials Other

  • New supplier
  • Improved materials
  • Other

• Please describe the action implemented

• Has this action been completed?

  Yes

  No

• Has this action been completed?

  Yes

  No

• Has this action been completed?

  Yes

  No

• What corrective actions have been implemented to improve the measurement aspects of this accident?

  Select Re-calibration Delays managed Other

  • Re-calibration
  • Delays managed
  • Other

• Please describe the action implemented

• Has this action been completed?

  Yes

  No

• Has this action been completed?

  Yes

  No

• Describe corrective action implemented

• Has this action been completed?

  Yes

  No

• What corrective actions have been implemented to improve the equipment used in this accident?

  Select Fixed equipment Quarantined equipment Disposed of equipment Other

  • Fixed equipment
  • Quarantined equipment
  • Disposed of equipment
  • Other

• Please describe the action implemented

• Has this action been completed?

  Yes

  No

• Has this action been completed?

  Yes

  No

• Describe the action required to improve the equipment used in the accident

• Has this action been completed?

  Yes

  No

• Has this action been completed?

  Yes

  No

• What corrective actions have been implemented to improve the process related to this accident?

  Select Process reviewed Process written Other

  • Process reviewed
  • Process written
  • Other

• Please describe the action implemented

• Has this action been completed?

  Yes

  No

• Has this action been completed?

  Yes

  No

• Has this action been completed?

  Yes

  No

• What corrective actions have been implemented to improve the environment associated with this accident?

  Select Improved waste management Additional spill equipment Controlled work area Other

  • Improved waste management
  • Additional spill equipment
  • Controlled work area
  • Other

• Please describe the action implemented

• Has this action been completed?

  Yes

  No

• Has this action been completed?

  Yes

  No

• Has this action been completed?

  Yes

  No

• Has this action been completed?

  Yes

  No

Verify and Determine the root cause

• You can use the simple Ishikawa principle to determine a potential root cause as a brain storming tool with the colleagues or the 5 Why process

  

• Which root cause analysis will you use?

  Select 5 Why Ishikawa Other

  • 5 Why
  • Ishikawa
  • Other
5 Why Analysis (click the green + button to complete)

• What is the problem you are going to root cause analyse

• Why?

• Why?

• Why?

• Why?

• Why?

• As determined by the 5Why above, what are the Immediate/Direct Causes (circumstances that immediately precede the accident)

  Select Slip Trip Stab / Puncture Cut / Laceration Lifting / Carrying Pushing / Pulling Fall (same level) Fall from height Unauthorised use of equipment Not wearing required PPE Not following training Struck by moving vehicle Equipment Fault or Failure Personal attack Contact with moving machinery Struck by falling / flying objects Contact with electricty Struck against fixed / stationary object Removal of safety guards Exposure / contact with harmful substance(s) Burns / Scalds from exposure to Fire or Heat Trap or Pinch Horseplay Non- Injury i.e. fainting, nose bleed, black out, rash, bee sting, etc.

  • Slip
  • Trip
  • Stab / Puncture
  • Cut / Laceration
  • Lifting / Carrying
  • Pushing / Pulling
  • Fall (same level)
  • Fall from height
  • Unauthorised use of equipment
  • Not wearing required PPE
  • Not following training
  • Struck by moving vehicle
  • Equipment Fault or Failure
  • Personal attack
  • Contact with moving machinery
  • Struck by falling / flying objects
  • Contact with electricty
  • Struck against fixed / stationary object
  • Removal of safety guards
  • Exposure / contact with harmful substance(s)
  • Burns / Scalds from exposure to Fire or Heat
  • Trap or Pinch
  • Horseplay
  • Non- Injury i.e. fainting, nose bleed, black out, rash, bee sting, etc.

• As determined by the 5Why above, what is the Basic/Root Cause for the accident?

  Select Personal/ Human Factors Job/ System Factors

  • Personal/ Human Factors
  • Job/ System Factors

• What was the Person/ Human Factor Root cause?

• What is the job/ system factor of the root cause

Define and implement Corrective Actions (e.g what actions can be taken to rectify the root casues identified in section 4)

• Include a Actions and assign a SMART objective

Verify Permanent Corrections (PCs) for Problem

• Can the issue be recreated by removing one or more of the results identified in section 5?

  Yes

  No

• Can the problem be corrected again by reinstating the results identified above?

  Yes

  No

Prevent Recurrence

• Has the problem has reoccurred since implementation of all actions.

  yes

  no

• The root cause analysis should be reviewed and additional prevenatative actions implemented

• Does a risk assessment exist for this task?

  Yes

  No

• Has the risk assessment been reviewed?

  Yes

  No

• The risk assessment must be reviewed before closing this investigation

• What is the risk assessment reference?

• A risk assessment must be devised and communicated. Please raise an action to complete an assessment as required in QSHE SOP 006

  

• Has the procedure/ process been updated?

  Yes

  No

• Have the results and improvements been communicated to all affected persons?

  Yes

  No

• Has the corrective action been witnessed?

  Yes

  No

• If the answer is yes to all of the above in this section, then the investigation is ready to be closed

End of Investigation - Sign off

• What time was lost due to the accident (mins/ hours/ days)?

• Team Leader sign off:

  Sign

• First Aider sign off:

  Sign

• Completion Date

  Date