ACCIDENT/INCIDENT INITIAL INVESTIGATION REPORT

• Type of investigation

  Accident

  Incident

  Near miss

• Client / Project:

• Type of accident/incident

  Select Personal Traffic H&S hazard Fire alarm Environmental incident H&S incident Near miss Other

  • Personal
  • Traffic
  • H&S hazard
  • Fire alarm
  • Environmental incident
  • H&S incident
  • Near miss
  • Other

• Name of place and area of accident/incident

• Date / time of accident/ incident

  Date

• Person(s) involved.

Injured party

• Name:

• Address:

• Phone number

• Person(s) involved.

Witness

• Name:

• Address:

• Phone number

• Person(s) involved.

Supervisor / Manager

• Name:

• Address:

• Phone number

• Time on duty:

  Date

• Time of last break:

  Date

• Weather conditions:

• Lighting conditions:

• Other contributory factors:

INJURED PARTY

Injured party details:

• Part of body injured:

• Company address and phone number:

• First aid given?

  Yes

  No

• Details of first aid provided

• Employee/visitor/contractor

  Employee

  Visitor

  Contractor

• Injured party was:-

  Sent to work

  Sent home

  Sent to hospital

• Details of any emergency services called (type, time called, time on site etc).

• Details of accident/incident:

• Sketch details if necessary:

  Drawing

• Add photos of location/injury/other information required for investigation assistance:

  Media

• Immediate actions taken:

• Findings of preliminary investigation by manager:

If vehicle, plant or equipment involved.

• Registration or serial number.

• Make/model

• Numbers of vehicles/plant involved.

• MOT or Certification expiry.

• Nature of damage.

• Insurance details.

• Name/signature and department of person completing this form.

  Sign

• Copied to:

  Select HSQE dept Project/site manager Personnel dept other

  • HSQE dept
  • Project/site manager
  • Personnel dept
  • other

• Use separate forms if a full investigation is required following a RIDDOR, hospital attendance, client or VHRL request.