Information
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Audit Title
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Accident Investigation Number:
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Accident Date and Time:
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Client / Site
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Conducted on
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Conducted on
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Prepared by
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NON-Conformance Closed out:
Company Information
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Name:
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Address:
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Phone:
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KPSS Investigator:
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KPSS Investigator Contact Details:
Employee Information:
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Name:
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Home Address:
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Phone:
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National Insurance Number:
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CSCS Card No:
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Add media
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Age:
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Sex:
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Department:
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Job Title:
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Employee Status:
- Full Time
- Part Time
- Self Employed
- Agency
- Other
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Length of Employment:
- Less Than 1 Month
- 1 - 5 Months
- 6 Months to 5 Years
- More Than 5 Years
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Time in Occupation/ at Work at Time of Accident:
- < 1 hour
- < 3 hours
- < 5 hours
- < 8 hours
- > 8 hours
Injury Information:
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Person Reported to:
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Date and Time Reported:
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Nature of Injury and Part of Body Affected:
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Indicate Location of Injury on Body
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Specific Task and Activity at the Time of Accident:
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How was the Injured Person Working
- Working Alone
- Working with assigned group
- Supervised
- Not Supervised
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Severity of Injury:
- Fatality - RIDDOR
- Specified injury - RIDDOR
- Lost days away from work > 7 - RIDDOR
- Days of restricted activity or job transfer
- Hospital treatment
- First aid
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Names of any Other Persons Injured, and Associated Accident Report Numbers:
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Name of Doctor that Reviewed Injury:
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Name and Address of Hospital / Clinic?
Witnesses:
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Name & Phone
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Name & Phone
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Name & Phone
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Name & Phone
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Name & Phone
Scene of Accident Information:
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Specific Location:
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Describe How the Accident/Incident Occurred:
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Diagram any Specific Location Factors That Contributed to the Accident/Incident
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Type of Equipment / Machinery Involved:
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Inspection and Maintenance details of Equipment / Machinery involved
- Out of Service
- Repaired
Accident Sequence: Describe in order of occurrence the events leading to the accident and/or injury. Reconstruct the sequence of events that led to the accident.
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Event 1
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Event 2
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Accident Event:
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Injury Event:
Causal Factors:
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Describe events and conditions that contributed to the accident. Include information on worker, machinery and equipment, environment and management.
Corrective Actions: Identify the factors listed above that can be corrected to prevent a reoccurrence of this type of accident. Indicate the person responsible for making the change and project a target date for completion of the task. Use the diagram grid below to illustrate layout changes.
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Causal Factor and Corrective Action
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Assignment Responsibilities:
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Target Date for Completion:
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Diagram:
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Pictures:
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Summary: Include comments that would promote a safe workplace environment and reduce an accidents potential in the future based on review of the causal Factors and implementation of Corrective Actions.
Confirmation by Individual that the Contents of this Report are to the best of their Knowledge Correct:
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Signature:
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Date:
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Title:
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Title / Position:
This Accident Investigation Report was prepared by:
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Signature:
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Date:
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Title:
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Department:
Client Senior Management Sign Off
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Signature:
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Date:
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Title: