ResourceMFG Accident Investgation

• Audit Title

• Document No.

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

Identification of Incident

• Date and Time incident took place

  Date

• Date and Time Incident reported

  Date

• Incident Reported By

• Where exactly did the incident take place

• Result of accident / action

  No injury

  First Aid administered

  Medical attention Dr Seen

  Sent or Taken to Hospital

  Fatal

• Type of Accident

  Select smash cut burn sprain or strain bruise no injury bite foreign body removal

  • smash
  • cut
  • burn
  • sprain or strain
  • bruise
  • no injury
  • bite
  • foreign body removal

• Has this incident resulted in Employees activities being modified or restricted by Dr.

  Yes

  No

• Has employee lost time due to the incident? If so? How many days? When is return to work expected?

  1 Day

  Up to 3 days

  3 - 6 Days

  7 Days or more

Incident description

• Describe in detail, how the incident occurred.

• Diagram of incident location

  Drawing

• Relevant evidential photos

  Media

• Was the person or persons involved performing normal job duties at the time of accident?

  Yes

  No

  N/A

• Was the person or persons involved, trained on how to carry out the task

  Yes

  No

  N/A

• Describe what equipment was involved in the accident.

• Was the equipment being used, suitable for purpose. Has it been checked.

  Yes

  No

  N/A

• If equipment was found to be unsuitable, what faults were identified and describe what action has been taken.

• Photo of equipment being used during the incident.

  Media

Injured Person(s)

• Name, Address,Date of Birth and Contact details of injured person.

• In what capacity was the injured person on your premises

  Staff Member

  Customer

  Contractor

  Visitor

  Other

• Describe injuries Sustained as a result of this incident

• Severity of injuries sustained

  No Injury (Near Miss)

  Minor

  Medium

  Severe

Cause of incident

• What do you believe to be the root cause of the accident?

  Select Human Error Equipment Failure Design Issues Lack of Training Communication Break Down Lack of Management Control Malicious

  • Human Error
  • Equipment Failure
  • Design Issues
  • Lack of Training
  • Communication Break Down
  • Lack of Management Control
  • Malicious

• What do you believe to be a contributing factor in the accident?

  Select Human Error Equipment Failure Design Issues Lack of Training Communication Break Down Lack of Management Control Malicious

  • Human Error
  • Equipment Failure
  • Design Issues
  • Lack of Training
  • Communication Break Down
  • Lack of Management Control
  • Malicious

• Explain your reasons / evidence to support the causation theory.

Recommendation for additional Control Measures

• Could this incident have been avoided. Was it foreseeable

  Yes

  No

  N/A

• What are your recommendations to prevent re-occurrence. Describe additional control measures required or relevant action required.

• Have control measures been implemented

  Yes

  No

  N/A

• How would you now rate the hazard status, following your implemented control measures

  Safe

  At Risk

  N/A

Enforcement Authorities & Action

• Has the incident been reported Medcor and corporate office?

  Yes

  No

  N/A

Investigation Summary

• Investigation Completed by

  Sign

• Position

  Select Group Security Manager RLPM LPO HR Manager Area Manager Store Manager Assistant Store Manager Floor Manager

  • Group Security Manager
  • RLPM
  • LPO
  • HR Manager
  • Area Manager
  • Store Manager
  • Assistant Store Manager
  • Floor Manager

• Other persons involved in investigation process / Site Manager

  Sign

• Position

  Select Group Security Manager RLPM LPO HR Manager Area Manager Store Manager Assistant Store Manager Floor Manager

  • Group Security Manager
  • RLPM
  • LPO
  • HR Manager
  • Area Manager
  • Store Manager
  • Assistant Store Manager
  • Floor Manager