Title Page

  • Site conducted

  • Conducted on

  • Prepared by

  • Location
  • Crime Ref No

  • Name of Police Officer in Attendance

  • Insurance Broker: Darwin Clayton,
    Darclay House
    9 Vernon Avenue
    Nottingham, NG9 2NS
    T: 01892 511 144
    F: 01892 511 455

Incident Details

  • Name of person involved in incident

  • Incident investigation team (Site rep, Lingwood rep etc.)

  • What task was being performed at the time of the incident

  • What happened? (e.g.injury, theft, vandalism etc')

  • Take photo evidence of incident

  • List of equipment damaged, stolen

  • Take photo evidence of surrounding environment (fence breaches, cabin damage, padlocks snapped, injuries etc.)

  • Immediate Cause of investigation

Immediate / Root Cause

  • Are there any obvious signs i.e. gates not locked, poor housekeeping, equipment not locked etc.

Contributing Factors

  • Select all the relevant contributing factors for each of the categories below.
    To create a corrective action click on the "Action" button, enter description of what we going to do to fix the problem, assign a due date, priority and person responsible.

  • Environmental factors (weather, lighting conditions, noise etc.)

  • Security staff inducted to site (photo of induction record required from site security folder)

  • Event log completed correctly (i.e. patrol times logged, site equipment listed, check calls recorded etc.) Photo of event log required

  • Seperate statement from guard required

  • Any other contributing factors (i.e. site restrictions, excavations, secondary site etc.)

  • Take photo evidence of any contributing factors

Preventative Measures Going Forward (Recommendations)

  • undefined

Sign off

  • Person involved in the incident

  • Supervisor

  • Site Rep

  • Lingwood Mgnr

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.