Safety Officer Services: Incident & Accident investigation

Safety Officer Services

Investigation Details

• Who will be leading this investigation?

• Please enter the date of this investigation.

  Date

• What kind of incident are you investigating?

  Accident

  Dangerous Occurence

  Near Miss

  Spillage

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

Incident Details

• Name of injured person (if any)

• Address
  Address

• When did the incident occur?

  Date

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

  Contractor

  Visitor

  TYK employee

  Agency employee

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

  Select Head Face Eyes Neck Shoulders Arms Hands Fingers Chest Stomach Upper leg Lower leg Foot Toes

  • Head
  • Face
  • Eyes
  • Neck
  • Shoulders
  • Arms
  • Hands
  • Fingers
  • Chest
  • Stomach
  • Upper leg
  • Lower leg
  • Foot
  • Toes

• 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.

  Media

• List all witnesses of the incident

Medical Treatment

• Was First Aid administered on-site

  Yes

  No

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

• Obtain signature of First Aider

  Sign

• Did you require any further treatment?

  Select A&E Urgent Care GP Visit

  • A&E
  • Urgent Care
  • GP Visit

• What was the outcome of this?

• Please provide dates and times

  Date

Witness Statement 1

• Please interview all witnesses and ask for signatures

• Name

• Address
  Address

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

  Sign

• Select date

  Date

Witness Statement 2

• Please interview all witnesses and ask for signatures

• Name

• Address
  Address

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

  Sign

• Select date

  Date

How did the incident/injury occur?

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

  Select Machine Fault Electric Fault Not paying attention Inexperience Floor/Building condition Other

  • Machine Fault
  • Electric Fault
  • Not paying attention
  • Inexperience
  • Floor/Building condition
  • Other

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

  Select Failure to wear PPE Inadequate Training Improper behaviour Poor Housekeeping Other

  • Failure to wear PPE
  • Inadequate Training
  • Improper behaviour
  • Poor Housekeeping
  • Other

• 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?

  Sign

• 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

  Yes

  No

• Is this incident reportable under Workcover

  Yes

  No

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

  Sign

• Signed by Lead Investigator

  Sign

• Signed by Assistant Investigator

  Sign

• Signed by Assistant Investigator

  Sign