Information
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Audit Title
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Document No.
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Client / Site
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Conducted on
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Prepared by
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Location
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Personnel
Incident details
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Date and time of incident;
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Name of injured or details of non injury incident
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Date of birth.
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Address of injured person.
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Injured parties work status.
- M Lambe Employee
- M Lambe Subcontractor
- Clients Employee
- Clients Subcontractor
- Visitor
- Member of Public
- M Lambe Apprentice
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Job Title.
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Name of Principal Contractor
- Balfour Beatty
- Bellway Homes West Midlands
- Bellway Homes Home Counties
- Bromford Homes
- Crest Nicholson
- David Wilson Homes
- Galliford Try
- Jelson Homes
- Jessup
- Keepmoat Homes
- Kier Homes
- Lovell Partnership
- McCarthy & Stone
- Miller Homes
- M Lambe Construction Ltd
- Morris Homes
- Persimmon Homes
- Walton Homes
- William Davis
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Site Address that the incident took place (Or other address where off site).
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Detailed description of location of incident (please be specific, plot numbers, chainage ref etc).
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Classification of Incident
- Minor Injury
- Dangerous Occurance
- 3 Day Injury
- 7 Day
- Non Fatal accident (non worker)
- 24hr Hospitalisation
- Specified Injury
- Occupational Disease
- Death
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Detailed description of injury stating clearly which body part affected and details of the item causing the injury.
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Sketch of location if not easily identified by plot number and/or photo
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Photos of location and associated aspects.
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Where was the Medical treatment first provided?
- On Site First Aid
- Off Site Doctor
- On Site Ambulance
- Off Site Hospital (A&E)
- Refused
- N/A
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Has this incident been recorded in the accident book? Or recorded as a near miss?
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who's?
- M Lambe Construction Ltd
- Client / PC
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Ensure where it has been recorded in the clients accident book that a copy is taken for our records and is sent to head office for secure storage and tracking (with injured parties consent).
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Were there any witnesses?
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Weather conditions.
- Clear
- Overcast
- Fog
- Snow
- Rain
- High Winds
- Extremely warm day
- Extremely cold day
- Dark (Low visibility)
- Below 0 degrees Celcius
Time line for the accident
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Set out the time line for the incident. this should include Task start time, incident time, response time (first Aid, Ambulance etc).
Who has been contacted, how and when?
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Emergency Services informed?
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Service Provider informed (Service Strike)
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HSE Informed?
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Police Informed?
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Client (PC) Informed?
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College (Apprentices)
Injured Party statement (where applicable)
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Name & Signature of the injured party
Witness statements
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Witnesses 1
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Name and signature of the witness 1
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Witnesses 2
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Name and signature of the witness 2
Injured Party Restrictions.
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Will the injured party have any restrictions following the incident?
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Further details on restrictions. Include information on job specific restrictions and assumed timescales in relation to these.
Action: Short Term
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Contributing causes of the Incident: (Inadequate training, Inadequate supervision. Employee not following correct safety procedures and instructions)
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What was the immediate action taken to correct the issue (how was this done):
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Who was the responsible party for correcting the issue:
Action: Long Term
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What is the long term action needed to correct the issue:
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Who was the responsible party for correcting the issue:
Additional Information
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Lessons Learned:
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Please provide attachments : Pictures, Drawings, Training Records, Statement of Employee, Statement of Witness/es, Other. Which may have been taken prior to this report being compiled.
Investigation Conclusions
Person Completing Form (please sign below)
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The above report a true reflection of the Incident to the best of my knowledge.
Manager/Supervisor in Charge (please sign below)
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The above report a true reflection of the Incident to the best of my knowledge.
Injured Party witnessing the completion of this document agrees with the content and that it is a true reflection of the Incident to the best of their knowledge.
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The above report a true reflection of the Incident to the best of my knowledge.
Person Accepting Liability (Where Applicable)
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Confirmation that the below accepts that a safe system of work, mandatory requirement, has not been followed which was a contributing factor in relation to the incident occurring.
Follow on Information.
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Was the incident classified as Reportable under RIDDOR?
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Name of person submitting RIDDOR report.
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Date of RIDDOR submission.
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Did the HSE or Police attend site?
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Give details including name of HSE Inspector, site representative who met them, and their findings.
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Was any action taken against M Lambe Construction Ltd in relation to this incident? If so what?
