The Safety Department Accident/Incident Investigation Report

• Audit Title

• Accident Investigation Number:

• Accident Date and Time:

  Date

• Client / Project/ Project Number

• Conducted on

  Date

• Prepared by

• NON-Conformance Closed out:

  Date

Company Information

• Name:

• Address:
  Address

• Phone:

• Investigator:

• Investigator Contact Details:

• HS10 AINM document completed

  Yes

  No

  N/A

• Has F2508 HSE RIDDOR Report been Completed

  Yes

  No

  N/A

Employee Information:

• Name:

• Phone:

• Home Address:
  Address

• Age:

• Sex:

• Sub- Contractor

• Job Title:

• CSCS Card Number & Run Out Date

• Employee Status:

  Select Full Time Part Time Self Employed Agency Other

  • Full Time
  • Part Time
  • Self Employed
  • Agency
  • Other

• Length of Employment:

  Select Less Than 1 Month 1 - 5 Months 6 Months to 5 Years More Than 5 Years

  • Less Than 1 Month
  • 1 - 5 Months
  • 6 Months to 5 Years
  • More Than 5 Years

• Time in Occupation/ at Work at Time of Accident:

  Select < 1 hour < 3 hours < 5 hours < 8 hours > 8 hours

  • < 1 hour
  • < 3 hours
  • < 5 hours
  • < 8 hours
  • > 8 hours

Injury Information:

• Person Reported to:

• Date and Time Reported:

  Date

• Nature of Injury and Part of Body Affected:

• Add photos of the injury

  Media

• Specific Task and Activity at the Time of Accident:

• How was the Injured Person Working

  Select Working Alone Working with assigned group Supervised Not Supervised

  • Working Alone
  • Working with assigned group
  • Supervised
  • Not Supervised

• Severity of Injury:

  Select Fatality - RIDDOR Specified injury - RIDDOR Lost days away from work > 7 - RIDDOR Days of restricted activity or job transfer Hospital treatment First aid

  • Fatality - RIDDOR
  • Specified injury - RIDDOR
  • Lost days away from work > 7 - RIDDOR
  • Days of restricted activity or job transfer
  • Hospital treatment
  • First aid

• Names of any Other Persons Injured, and Associated Accident Report Numbers:

• Name and Address of Hospital attended

Incident Record

• Detail of Incident

• Select date

  Date

• Location of Incident

• Add photos of the scene of the incident

  Media

Witnesses:

• Name & Phone

• Name & Phone

• Name & Phone

• Name & Phone

• Name & Phone

Scene of Accident/Incident Information:

• Specific Location:
  Address

• Add media

  Media

• Specific Location Factors That Contributed to the Accident/Incident

  Yes

  No

  N/A

• Add media

  Media

• Describe How the Accident/Incident Occurred:

• Type of Equipment / Machinery Involved:

• Add media

  Media

• Inspection and Maintenance details of Equipment / Machinery in operation

  Select Out of Service Repaired Certified & Tested

  • Out of Service
  • Repaired
  • Certified & Tested

• Add media

  Media

Accident/Incident Sequence: Describe in order of occurrence the events leading to the accident/Incident and/or injury. Reconstruct the sequence of events that led to the accident.

• Event 1

• Accident Event:

• Injury Event:

Causal Factors:

• Describe events and conditions that contributed to the accident. Include information on worker, machinery and equipment, environment and management.

Corrective Actions: Identify the factors listed above that can be corrected to prevent a reoccurrence of this type of accident. Indicate the person responsible for making the change and project a target date for completion of the task. Use the diagram grid below to illustrate layout changes.

• Causal Factor and Corrective Action

• Assignment Responsibilities:

• Target Date for Completion:

• Pictures:

  Media

• Summary: Include comments that would promote a safe workplace environment and reduce an accidents potential in the future based on review of the causal Factors and implementation of Corrective Actions.

Confirmation by Area Construction Manager that the Contents of this Report are to the best of their Knowledge Correct:

• Signature:

  Sign

• Date:

  Date

• Position:

This Accident Investigation Report was prepared by:

• Signature:

  Sign

• Date:

  Date

• Title:

• Department:

This Report has been reviewed by:

• Peter Barlow, CMIOSH, IMaPS, FIIRSM, MIIAI

• KP Safety Solutions Ltd

• Add signature

  Sign

• Select date

  Date