Incident Report & Investigation

Accident / Incident / Near Miss Report

• Document No.

• Site Name & City/Town

• Conducted on

  Date

• Prepared by

• Add signature

  Sign
• Location
  Address

Brief description of incident

• Yes

  No

  N/A
• Location of Incident (Site, Plot No. Room Etc.):
  Address

• Date & Time of Incident:

  Date

• Date Reported to Health & Safety Manager:

  Date

Employment details:

• Employment Details:

  Select Employee Contractor

  • Employee
  • Contractor

• Employers Name:

• Employers Address:

Details of damage caused (if applicable)

• Nature of incident:

• Add media

  Media

Site conditions at the time of the Incident:

• Weather etc:

Other:

• Was any machinery involved?

  Yes

  No

  N/A

• Were any photos taken?

  Yes

  No

  N/A

• Add media

  Media

What action was taken immediately after the incident?

• Enter description

The way forward

• Can any improvements be made as a result of this incident?

  Select Yes No

  • Yes
  • No

What improvements are required?

• Details

• Add media

  Media