Trio Construct Incident/Hazard Investigation Report

General

• Employer

• Site address
  Address

• Employee or Subcontractor

• Date of incident/hazard

  Date

Injured Person

• Name

• Age

• Address

• Telephone

Accident

• Day/Date of incident

  Date

• Date and time reported

  Date

• Person who reported Incident

• Incident Location

• Task being carried out at the time of the incident

• Reconstruct sequence of events leading up to incident

• Possible cause of incident

• Nature of injuries

• Estimated time off work

• Witnesses statement

• Witnesses statement

• Witnesses statement

General Incident Description

• Briefly describe what happened

Prevention

• Briefly describe what action has been taken to prevent a reoccurrence of the incident

• Person investigating accident

• Signature

  Sign

• Date of report

  Date