SHEQ Managers Accident, Incident or Near Miss Investigation Report

• Document No.

• Audit Title

• Client / Site

• Conducted on

  Date
• Location of Accident, Incident or Near Miss
  Address

• Prepared by

• Distribution

  Select Martin Lynskey Stella Lynskey Dean Miller Jeff Pratt Helen Doyle Other

  • Martin Lynskey
  • Stella Lynskey
  • Dean Miller
  • Jeff Pratt
  • Helen Doyle
  • Other

• Please state persons to be informed

Notification

• Notified by?

  Select Wath Head Office Skip Hire Earthworks & Soil Stabilisation Excavations Transport Manager Office Manager SHEQ Manager Site Manager Other

  • Wath Head Office
  • Skip Hire
  • Earthworks & Soil Stabilisation
  • Excavations
  • Transport Manager
  • Office Manager
  • SHEQ Manager
  • Site Manager
  • Other

• Please state person notifying of incident

• Please state

• Department / Area?

• Date of notification

  Date

Incident

• Date and Time of Incident?

  Date

• Type of Incident

  Accident

  Incident

  Near Miss

  RIDDOR

• Was first aid treatment required?

  No

  Yes

• Please state treatment

• Was hospital treatment required?

  No

  Yes

• Any further information?

• Type of Injury?

• Did the incident result in lost time?

  No

  Yes

• If yes, how many days

• Description of the Accident, Incident or Near Miss.

Forms

• Has the Accident form been received?

  Yes

  No

• Has the Internal Accident / Incident / Violence Report form been received?

  Yes

  No

Details of Involved Parties

• Name of Employees Involved?

• Name and details of witnesses?

Other Information Requirements

• Information required for a possible Claim or RIDDOR?

  Select Training Records Qualification Records Job Log Risk Assessments Accident Form N/A

  • Training Records
  • Qualification Records
  • Job Log Risk Assessments
  • Accident Form
  • N/A

Actions from the Investigation

• SHEQ Managers Comments?

• Action Taken?

• Status?

  Open

  Closed

• Date of Conclusion?

  Date

Signature

• SHEQ Managers Signature.

  Sign