Investigation

Investigation Details

  • Who will be leading this investigation?

  • Please enter the date of this investigation.

  • What kind of incident are you investigating?

  • Please add the accident/dangerous occurrence reference number this investigation relates too.

Incident Details

  • Name of injured person (if any)

  • Address
  • When did the incident occur?

  • What type of person was injured? (if any)

  • Which part of the body was injured? (if any)

  • Give details of any tasks being carried out at the time of the incident/injury?

  • Have all persons involved in the incident received information, instruction and training for the tasks relating to the incident?

  • Describe in detail what happened?

  • Describe in detail any injury sustained, if no injury, describe any damaged equipment, plant or machinery etc

  • Do you think any persons involved in the incident are negligent in any way, if yes, describe how.

  • Please add as many images as you can that relate to the incident.

  • List all witnesses of the incident

Medical Treatment

  • Was First Aid administered on-site

  • Describe what assistance was provided by the First Aider, list any medical equipment used (plasters, bandage, eyewash etc.)

  • Obtain signature of First Aider

  • Did you require any further treatment?

  • What was the outcome of this?

  • Please provide dates and times

Witness Statement 1

  • Please interview all witnesses and ask for signatures

  • Name

  • Address
  • I confirm that the information I have provided in relation to this incident is accurate.

  • Select date

Witness Statement 2

  • Please interview all witnesses and ask for signatures

  • Name

  • Address
  • I confirm that the information I have provided in relation to this incident is accurate.

  • Select date

How did the incident/injury occur?

  • Please list the main cause or causes of this incident or injury

  • Please list any contributing factor or factors relating to this incident or injury

  • Describe in detail your findings as to how the incident has occurred?

Corrective and Preventive Action

  • What corrective actions have been taken immediately?

  • Who carried out the corrective actions?

  • Describe what actions can be taken to prevent a recurrence of this incident (Improved training, PPE, improved housekeeping, improved maintenance etc)

  • Provide a monthly timescale for any improvements that will be made?

Incident Reporting

  • Did the injured person require time off work

  • Is this incident reportable under Workcover

Results of Investigation

  • Explain the results of your findings, take into account all factors and provide a balanced view, if there is a clear cause for the incident, be sure to list it.

  • If any equipment, plant, machinery have been damaged please list and describe the issues

Authorisation

  • I agree that all information provided by this investigation is accurate.

  • Signed by injured person

  • Signed by Lead Investigator

  • Signed by Assistant Investigator

  • Signed by Assistant Investigator

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