Safety, Health & Environmental Accident Report & Investigation Form

• Type of incident

  Select

• Report Number

• Date received

  Date
• Location
  Address

• Record as much details as possible , including the name of any substance involved, the type of machinery in use, any damage to property, the events that led up to the incident and the part played by other people

• Details

• If required, pictures or sketches of the details of the incident can be uploaded here

  Media

• Precise nature of the injury

First Aid

• Detail the first aid treatment provided and by whom, include any hospital treatment required and the length of stay

Witnesses

• Name of Witness 1

• Witness statement obtained?

  Yes

  No

  N/A

• Name of Witness 2

• Witness statement obtained?

  Yes

  No

  N/A

• Name of Witness 3

• Witness statement obtained?

  Yes

  No

  N/A

• Signature of injured person

  Sign

• Date

  Date

• Agreed action Measures - To be completed by the Section Team leader/Manager immediately following the investigation-

• Action to be carried out by

• Proposed completion Date

  Date

• Agreed by

• Signature

  Sign

• Date

  Date

• Please attach a copy of the relevant SOP and Risk assessment relating to this accident

Other details

• Has the accident book been filled in?

  Yes

  No

  N/A

• Is the post-accident risk assessment / SOP revision required

  Yes

  No

  N/A

• Is the accident / Incident reportable to HSE?

  Yes

  No

  N/A

• Reported by

• Date Reported

  Date

• Have the necessary corrective/preventative measures been completed and proven effective- To be completed by HSEQ office following completion of the proposed corrective actions

  Yes

  No

  N/A

• If no, Give details

  Yes

  No

  N/A

• Audit by

• Signature

  Sign

• Date

  Date

• Have the necessary corrective /preventative measures been completed and proven effective?

  Yes

  No

  N/A

• If no, Give details

  Yes

  No

  N/A

• Audit by

• Signature

  Sign

• Date

  Date