Information

  • Document No.

What is being reported

  • A near miss or dangerous occurrence

  • Damage to a building or property

  • An incident resulting in injury

  • A violent incident

  • A case of work related ill health

  • When did the incident occur

  • Client / Site

  • Wide area picture of site

  • Incident investigator

Part A

PART A

Contact details of incident investigator filling in this form including tel & email address

Type of Accident

Description of incident

  • What time & date did the incident occur?

  • What was the exact location of the incident. Include address, building or grid reference and room name/number.
  • What happened? Describe the incident. Give as much information as possible. Include what was happening at the time the incident occurred.

  • Relevant photos or video

  • Date & time of videos or video

  • If this was a violent incident, what was the nature of the incident?

  • Weather Conditions eg Rain, sleet, snow, dry

  • Visibility e.g. Fog, haze, dark, overcast etc

  • Surface type

  • Type of footwear person was wearing

  • Was the footwear in good condition?

Police involvement

  • Were the police informed?

  • Date anytime police informed

  • How were the Police informed?

  • Crime number

  • Notes

Injury details

  • Describe the exact parts of the body injured

  • Full name of injured person

  • ID number of injured person :

  • Photo of ID document.

  • Date of birth

  • Male or Female

  • Home address
  • Contact number

  • Employer address if contractor or agency
  • Next of kin name and tel

Treatment given

  • Details of Treatment

Classification of injured person

  • Employee

  • Member of public

  • Agency worker

  • Contractor

Witness information

  • We're there any witnesses to this incident?

  • Witness name

  • Witness contact number and email address

  • Witness postal address
  • Statement of witness to accident/incident

  • Witness statement

  • Witness statement(if not scanned in above)

  • Any photos taken by witnesses

  • Was there CCTV footage captured, what is shown

Report

  • To Whom was the Incident reported to at site

  • When was the incident reported

  • We're any other agencies or external bodies informed. If so who and when?

  • Any additional Information

Part B

Part B

DOL reporting - if anyone was injured were they....

  • An employee who lost consciousness or needed resuscitation

  • An employee who suffered a major injury

  • An employee who was hospitalised for more than 24 hours

  • An employee who was absent for more than 7 consecutive days

  • A member of the public, visitor etc, who was taken to hospital direct from the site of the incident

  • Has the incident been reported under DOL

  • If reported under DOL, when?

  • If reported under DOL, who made the report?

  • Compensation provider:

  • Compensation number:

Disposal

  • What initial treatment was given

  • What happened to the casualty

  • How were they transported and who by

  • If the person went to a medical facility, which one.

The Investigation

  • Incident layout

  • Detail any potential causes of the incident that have been identified during the investigation

  • Sequence of events

  • Overall activity

  • Individual activity

  • Condition factor (Direct cause)

  • Equipment factor (direct cause)

  • Process factor (direct cause)

  • Organizational factor (root cause)

  • Human factor (root cause)

  • Job factor (root cause)

  • Personal factor (root cause)

Root Cause Analysis report

  • What

  • When

  • Where

  • Who

  • Why

  • What if

  • Cause and Effect Summary

  • Relevant media

Actions taken to prevent recurrence

  • Detail all actions taken

  • Is a further detailed investigation required?

Media

Photos

  • Add media

  • Add media

  • Add media

  • Add media

  • Add media

  • Add media

  • Add media

  • Add media

Videos

  • Add media

  • Add media

  • Add media

Voice notes

  • Add media

  • Add media

Incident Investigator

Incident Investigator Sign Off on Investigation

  • Investigator name and surname

  • Contact details :

  • Email

  • Date and time

  • Sign off of investigator

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.