Information

  • Client / Site

  • Prepared by

  • Conducted on

Section 1

THIS DOCUMENT IS SPLIT INTO 2 SECTIONS. TOGGLE THROUGH THE SECTIONS AT THE BOTTOM OF THE PAGE.

SECTION 1 - Accident/Incident Type

  • Select either 'Personal', Event' or 'Near Hit'

  • PERSONAL (non work related injury)

  • EVENT - Accident/incident resulting in injury, illness, damage or harm.

  • NEAR HIT - An incident that had the potential in resulting in injury, illness, damage or harm.

NOTE: For 'Near Hit' complete investigation in relation to potential outcome of incident.

  • Report Status

  • Revised Status (if revised)

Once both Sections are complete email to safety department to complete further investigation.

Section 2

THIS DOCUMENT IS SPLIT INTO 2 SECTIONS. TOOGLE THROUGH THE SECTIONS AT THE BOTTOM OF THE PAGE.

SECTION 2 - Incident Details

  • Date and Time of Accident/Incident

  • Date and Time of Investigation Report

  • Person(s) Carrying Out Investigation

  • Contractor

  • Contract Persons' Drivers Licence

  • Location of Accident/Incident
  • Activity at Time of Accident/Incident

Person(s) Involved

  • Supervisor

  • Safety Advisor/Representative

  • Witness 1

  • Witness 2

  • Witness 3

What Happened/What Was Observed

  • Please only state factual information.
    Examples: What is the damage or loss - What was the injured party doing - What had the injured party been instructed to do - What tools were being used - What did the injured/witness see - What safety rules were violated - What safety procedures were in place - What permits were being used - What isolation procedures were in place - What training had been given - What communication system was in place at the time

  • Statement 1

  • Name and Signature

  • Statement 1

  • Name and Signature

  • Statement 1

  • Name and Signature

  • Statement 1

  • Name and Signature

  • Statement 1

  • Name and Signature

Once both Sections are complete email to safety department to complete further investigation.

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.