Identification of Incident

  • Date and Time incident took place

  • Date and Time Incident reported

  • Incident Reported By

  • Where exactly did the incident take place

  • Result of accident / action

  • Type of Accident

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

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

Incident description

  • Describe in detail, how the incident occurred.

  • Diagram of incident location

  • Relevant evidential photos

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

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

  • Describe what equipment was involved in the accident.

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

  • 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.

Injured Person(s)

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

  • In what capacity was the injured person on your premises

  • Describe injuries Sustained as a result of this incident

  • Severity of injuries sustained

Cause of incident

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

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

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

Recommendation for additional Control Measures

  • Could this incident have been avoided. Was it foreseeable

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

  • Have control measures been implemented

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

Enforcement Authorities & Action

  • Has the incident been reported Medcor and corporate office?

Investigation Summary

  • Investigation Completed by

  • Position

  • Other persons involved in investigation process / Site Manager

  • Position

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