QMF028

General

• Name of casualty

• Date

  Date

• Time

  Date

• Location

• Brief details of accident/incident

• Did/could the accident/incident result in significant loss/injury?

  Yes

  No

Plant and Machinery

• Was plant or machinery involved?

  Yes

  No

• If yes, details:

• Any defects present?

  Yes

  No

• If yes, details:

• Date of last test/inspection

Hazardous Substances

• Were any hazardous substances involved?

  Yes

  No

• If yes, details:

• Have Material Safety Data Sheets been provided?

  Yes

  No

Risk Assessment

• Has the task or workplace been subject to risk assessments in the following areas?

• General

  Yes

  No

  N/A

• Manual Handling

  Yes

  No

  N/A

• COSHH

  Yes

  No

  N/A

• Noise

  Yes

  No

  N/A

• PPE

  Yes

  No

  N/A

• Fire Precautions

  Yes

  No

  N/A

• Other

  Yes

  No

  N/A

• Give details:

• Are the Control Measures identified in the Risk Assessment suitable?

  Yes

  No

• If no, give details:

• Have Control Measures been implemented?

  Yes

  No

• If no, give details:

Safety Measures

• Have witnesses to the accident/incident been identified?

  Yes

  No

• Please attach Witness Statements to this report

• Have their account of the accident/incident been obtained?

  Yes

  No

• Were any contractors' employees involved?

  Yes

  No

• If yes, details:

• Have employees received adequate information, instruction, & training to undertake the task safely?

  Yes

  No

• Give details:

• Was all equipment needed for the task provided?

  Yes

  No

  N/A

• Was this equipment being used correctly?

  Yes

  No

• Was there adequate levels of supervision?

  Yes

  No

  N/A

• Is a Safe System of Work / Safe Working Procedure in place?

  Yes

  No

  N/A

• Are employees fully aware of the requirements of the Safe Systems/Procedures?

  Yes

  No

• Were any employees not following instructions?

  Yes

  No

• If yes, details:

Safety Inspections

• Had the workplace been subject to safety inspections?

  Yes

  No

• If yes, give date & details:

• Details of any deficiencies

Hazard Reports

• Have hazards relating to the task/workplace been reported?

  Verbally

  In writing

  N/A

• Give details:

• Details of any deficiencies

Working Environment

• Were any of the following factors present or extant?

• Floors:

  Select Uneven Slippery Wet N/A

  • Uneven
  • Slippery
  • Wet
  • N/A

• Lighting:

  Select Excessive N/A

  • Excessive
  • N/A

• Temperature:

  Select Too hot Too cold N/A

  • Too hot
  • Too cold
  • N/A

• Noise levels:

  Select Excessive N/A

  • Excessive
  • N/A

• Working space:

  Select Restricted N/A

  • Restricted
  • N/A

Conclusions

• Comments:

• Photos

  Media

• Investigated by

  Sign

• Date

  Date