Title Page
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Site conducted
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Conducted on
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Prepared by
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Location
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Department
Incident Details
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Employees involved
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Location of Incident
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Date of Incident
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Time of Incident
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Was the IP Injured or suffer from ill health
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What was the injury or ill health
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Did the incident cause damage to any property
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What property was damaged
Investigation Details
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Overview of the event
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Activities being performed
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Equipment in use
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Work conditions
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Was the IP Competent
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How have you deemed the person competent
Cause of the Incident
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What was the immediate cause
- Struck by moving object
- Hit by falling object
- FLT Issue
- Spill
- Braking hard
- Using unauthorised tools
- Speeding
- Slip Trip or Fall
- Other
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Specify
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What was the underlying cause
- FLT Leaking
- Rushing to get the job done
- lack of maintenance or inspection
- Taking a short cut
- Other
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Specify
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What was the root cause
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Specify
Risk Control
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What Risk Control measures can we put in place to stop re-occurrence
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Who is the owner of the actions
Risk Assessments & Safe Systems of Work
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Was the activity covered under a Risk Assessment
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What Risk Assessment(s)
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Has the Risk Assessment been reviewed and does it require changing
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Who have you raised this with
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Review it and make any changes with support of SHEQ
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Has this been raised to SHEQ
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Was the activity covered under a Safe System of Work
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Has this been raised to SHEQ
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What Safe System of Work
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Has the SSoW been reviewed and does it require changing
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Who have you raised this with
Information
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IS there any further details we need to know
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Who was part of the investigation
Sign Off
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Name
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Position
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Date
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Sign
