Incident Investigation Report

• Document No.

• Client / Site / Project

  Select

• Site Address

  Select

• Date & Time that this report was conducted

  Date

• Person Conducting the Report

Personal Details for the Injured Person

• Name

  Select

• Gender

  Male

  Female

  Prefer not to say

• Date of Birth

  Date

• Contact Number

• Current Address

  Select

• Signature of Injured Person

  Sign

Incident Details

• Date & Time of Incident

  Date

• Exact Location of Incident

• Weather Conditions at the time of the Incident?

  Select Clear Dry Sunny Foggy Cloudy Wet Windy Hot Cold Snowy Icy Other

  • Clear
  • Dry
  • Sunny
  • Foggy
  • Cloudy
  • Wet
  • Windy
  • Hot
  • Cold
  • Snowy
  • Icy
  • Other

• Nature of Injury

  Select Superficial Open Wound Fatality Concussion Sprain Respiratory Eye Injury Burns Fracture Electrocution Fall Strain Dislocation Struck by object Entanglement Assault Muscle & Tendon Nerve & spinal cord Amputation Intracranial Other Injury

  • Superficial
  • Open Wound
  • Fatality
  • Concussion
  • Sprain
  • Respiratory
  • Eye Injury
  • Burns
  • Fracture
  • Electrocution
  • Fall
  • Strain
  • Dislocation
  • Struck by object
  • Entanglement
  • Assault
  • Muscle & Tendon
  • Nerve & spinal cord
  • Amputation
  • Intracranial
  • Other Injury

• Injury sustained - (Body Location).

  Select General Ailment Head Eye (Left) Eye (Right) Ear Nose Throat Neck Back (Upper) Back (Lower) Arm - Upper (Right) Arm - Upper (Left) Arm - Elbow (Right) Arm - Elbow (Left) Arm - Forearm (Right) Arm - Forearm (Left) Wrist (Right) Wrist (Left) Hand (Right) Hand (Left) Chest Abdominal / Stomach Groin / Anus Leg - Upper (Right) Leg - Upper (Left) Leg - Knee (Right) Leg - Knee (Left) Leg - Lower (Right) Leg - Lower (Left) Ankle (Right) Ankle (Left) Foot (Right) Foot (Left) Shoulder (Left) Shoulder (Right) Other

  • General Ailment
  • Head
  • Eye (Left)
  • Eye (Right)
  • Ear
  • Nose
  • Throat
  • Neck
  • Back (Upper)
  • Back (Lower)
  • Arm - Upper (Right)
  • Arm - Upper (Left)
  • Arm - Elbow (Right)
  • Arm - Elbow (Left)
  • Arm - Forearm (Right)
  • Arm - Forearm (Left)
  • Wrist (Right)
  • Wrist (Left)
  • Hand (Right)
  • Hand (Left)
  • Chest
  • Abdominal / Stomach
  • Groin / Anus
  • Leg - Upper (Right)
  • Leg - Upper (Left)
  • Leg - Knee (Right)
  • Leg - Knee (Left)
  • Leg - Lower (Right)
  • Leg - Lower (Left)
  • Ankle (Right)
  • Ankle (Left)
  • Foot (Right)
  • Foot (Left)
  • Shoulder (Left)
  • Shoulder (Right)
  • Other

• Incident Priority

  Urgent

  High

  Medium

  Low

  Trivial

• Is the Incident RIDDOR Reportable?

  Yes

  No

• Please give a reason why the incident is reportable under RIDDOR Regulations 2013

  Select Death Fractures, other than fingers, thumbs & toes Amputations Any injury likely to lead to the permanent loss or reduction of sight Any crush injury to the head or torso causing damage to the brain or internal organs Serious burns (including scalding) which: covers more than 10% of the body or causes significant damage to the eyes, respiratory system or other vital organs Any scalping requiring hospital treatment Any loss of consciousness caused by head injury or asphyxia Any other injury arising from working in an enclosed space which: leads to hypothermia / heat-induced illness or requires resuscitation or admittance to hospital for more than 24 hours Over 7-Day incapacitation of a worker: Accidents must be reported where they result in an employee or self-employed person being away from work, or unable to perform their normal work duties, for more than seven consecutive days as the result of their injury. This seven day period does not include the day of the accident, but does include weekends and rest days. The report must be made within 15 days of the accident. Other

  • Death
  • Fractures, other than fingers, thumbs & toes
  • Amputations
  • Any injury likely to lead to the permanent loss or reduction of sight
  • Any crush injury to the head or torso causing damage to the brain or internal organs
  • Serious burns (including scalding) which: covers more than 10% of the body or causes significant damage to the eyes, respiratory system or other vital organs
  • Any scalping requiring hospital treatment
  • Any loss of consciousness caused by head injury or asphyxia
  • Any other injury arising from working in an enclosed space which: leads to hypothermia / heat-induced illness or requires resuscitation or admittance to hospital for more than 24 hours
  • Over 7-Day incapacitation of a worker: Accidents must be reported where they result in an employee or self-employed person being away from work, or unable to perform their normal work duties, for more than seven consecutive days as the result of their injury. This seven day period does not include the day of the accident, but does include weekends and rest days. The report must be made within 15 days of the accident.
  • Other

• If the Incident needs to be reported please follow the correct procedures as contained within the media attachment.

Treatment

• Was First Aid Treatment Given?

  Yes

  No

• Name of the First Aider administering treatment?

• Description of Treatment Given?

• Did the Injured Person go to Hospital?

  Yes

  No

• Name of Hospital that the Injured Person attended?

• Was Proof of Attendance Given - (Doctors Note etc?)

  Yes

  No

• Injured Person Statement

Witness Details

• Name of Witness

  Select

• Contact Number

• Witness Address

  Select

• Witness Statement

• Has a Witness Statement been Given

  Yes

  No

• Signature of Witness

  Sign

• The reason for conducting root cause analysis is to identify and address the underlying causes of a problem or issue, rather than just treating the symptoms. By understanding the root causes, our organisation can implement effective solutions that prevent the problem from recurring in the future. Root cause analysis helps to improve processes, enhance performance, and minimise the risk of similar problems or incidents happening again. It also enables our organisation to make informed decisions, allocate resources efficiently, and continuously improve our operations.

• What were the contributing Factors to this incident occurring? - (Select all that apply).

  Select Safety Policies & Procedures not followed Un-authorised use of Equipment Incorrect use of PPE Lack of necessary PPE / RPE Lack of Training / Knowledge Poor Supervision Poor Communication Poor Housekeeping Poor Ventilation Drugs & Alcohol abuse Horseplay Physical Violence Other

  • Safety Policies & Procedures not followed
  • Un-authorised use of Equipment
  • Incorrect use of PPE
  • Lack of necessary PPE / RPE
  • Lack of Training / Knowledge
  • Poor Supervision
  • Poor Communication
  • Poor Housekeeping
  • Poor Ventilation
  • Drugs & Alcohol abuse
  • Horseplay
  • Physical Violence
  • Other

• Has the root cause of the incident been identified?

  Yes

  No

Any Further Considerations / Suggestions

• Due to the information contained within this report are there any further recommendations / actions to be implemented?

  Yes

  No

• Please list the actions to be implemented

  Issue Toolbox Talk

  Issue Safety Briefing

  Recommend Training

  Issue Disciplinary Action

  Other

• Predicted Timescale for solution / Action to be implemented?

  Select Same Day 1-Day 1-Week 2-Weeks 3-Weeks 1-Month N/A Other

  • Same Day
  • 1-Day
  • 1-Week
  • 2-Weeks
  • 3-Weeks
  • 1-Month
  • N/A
  • Other

Sign Off

• Signature of the person conducting this investigation report

  Sign