Investigation [Accident / Incident]

• Document No.

• Accident / Incident Date

  Date

• Client / Site

• Conducted on

  Date

• This report must only be passed to / read by personnel who have been authorised.
  
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  Viewing this document when you have not been authorised will be classed as GROSS MISCONDUCT.

Investigator(s)

• Name and job title of person(s) carrying out investigation

Date, Time, Location, Weather

• Date & time of incident

  Date
• Address of incident
  Address

• Exact Location of incident

• Weather at time of incident

Description of events

• Describe how incident occurred (who, when, where, how)

• Relevant Photos

  Media

Accident Category

• Major Injury

• Over 7 Day Injury

• Minor Injury

• Occupational Illness

• Dangerous Occurrence

• Property Damage

• Business Loss

• Vehicle Accident

• Near Miss

• Fatal Injury

• Lost Time Injury

• Notifiable "not at work" Injury

• Notifiable Vehicle Injury

• Vehicle Injury

• Environmental Accident

Parts of Body Injured

• Arm (Left)

• Arm (Right)

• Back

• Eye (Left)

• Eye (Right)

• Foot (Left)

• Foot (Right)

• Hand (Left)

• Hand (Right)

• Head

• Leg (Left)

• Leg (Right)

• Trunk

Injury Type

• Amputation

• Burn

• Bruise

• Cut/Graze

• Foreign Body

• Fracture

• Loss of Consciousness

• Scald

• Strain/Sprain

Incident Kind

• Animal

• Collapse / Overturning

• Contact with Machinery

• Contact with Materials

• Drowning / Asphyxiation

• Electricity

• Exposure to Explosion

• Exposure to Fire

• Fall from height

• Harmful Substance

• Lifting or Carrying

• Slip / trip / fall (same level)

• Struck by Object

• Struck by Vehicle

• Struck by Stationary Object

Details of person(s) injured / involved.

• Name and job titles of person(s) injured / involved

• Male or Female

  Female

  Male

• Status

  Employee

  Self-employed

  Contractor

  Visitor

  Work Experience

• Date of BirthY

  Date

• Years Service

• Number of hours worked since the start of shift

Root Cause

• Describe the Root Cause

• Relevant Photos

  Media

• Name any contributing factors

• Relevant Photos

  Media

Preventative Actions

• Bullet point preventative actions that will be taken to reduce the likelihood of reoccurrence of this type of incident