ACCIDENT AND INCIDENT INVESTIGATION REPORT

Name of employer      

Accident book reference number      

Name of injured person      

Are they an employee visitor contractor other [specify]

Exact location of the accident or incident      

Manager or supervisor in charge of area      

where the accident or incident occurred

Date of accident or incident      

Time of accident or incident (24-hour clock)      

Did the accident or incident require reporting to the authorities? (Include Yes No
any report to the emergency services or the enforcing authorities.)

How and when the accident or incident was      

reported to the authorities?

Were there any witnesses to the accident or incident? Yes No

Details of witnesses (names, addresses      

and contact telephone numbers, etc)

Have the witnesses provided statements? Yes No

Has the person(s) involved in the accident provided statements? Yes No

Has the site of the accident been made safe for the investigation team? Yes No

Have all physical details been recorded (photos/sketches)? Yes No

Have samples been collected of substances and materials? Yes No

Attach any additional information, statements, photographs, and enforcing authority report, etc to this
document as appendices.
Details of the accident or incident
Description (Provide a summary of events leading up to the accident or incident with details of the
circumstances immediately prior to the event plus working conditions — weather, visibility, temperature,
housekeeping standards, unusual working conditions, etc.)
     
Were there any injuries sustained? Yes No

Nature of injury, eg fracture, crush, laceration,      

bruising, etc

Location of injury, eg leg, arm, body, hand,      

head, etc
First-aid treatment administered
     

Name(s) of first aider or appointed person(s)      

Did the injured person lose consciousness? Yes No

Was the injured party admitted to hospital? Yes No

Give details
     

Is the injury likely to cause a loss of working time? Yes No

Give details
     

Briefly describe what the injured person was actually doing at the time of the accident or explain the
circumstances leading up to the incident
     

Was the person authorised to be in the area? Yes No

If Yes, who gave the authorisation and for      

what purpose?
How long had the injured person, or the person involved, been carrying out this activity? (Describe the
person's experience in doing this activity over time.)
     

List any risk assessments undertaken for the activity involved in the accident or incident. (Include
reference numbers, dates of assessment and review, appropriate control measures required, etc; copies
of relevant risk assessments should be made available for examination.)
     
Explain how the findings of risk assessments had been explained to the workforce.
     

Was there a safety procedure in place? Yes No

If Yes, give details of documented safe systems of work or instructions given.
     

Was the procedure being followed prior to the accident or incident? Yes No
Environment — were there any environmental conditions that may have had a bearing on the accident or
incident (eg adverse weather, wind, sunlight, rain, poor lighting, wet floor, etc)?
     

Was any protective clothing and equipment required, was it available and was it in use? (Give details.)
     

Were any safety devices required, were they available and in use? (Give details.)
     

Was any equipment or machinery involved? (Name of equipment or machinery, part of equipment or machinery
causing injury, was the equipment or machinery in motion and were there any faults found with the equipment or
machinery or its guarding, had planned guard checks been carried out where applicable?)
     

Were any hazardous substances involved in the accident or incident? Yes No

If Yes, give details.
     

Describe the supervision in place at the time of the accident or incident.

     

Was the person involved trained in regard to this activity? Yes No

If Yes, describe what training had been provided — full training records should be made available for examination.
     
Have all the risk assessments associated with the accident or Yes No
incident been reviewed?
What in your opinion do you consider were the actual and probable causes of the accident or incident?
(Use short phrases.)
     

Explain any remedial action taken or required to prevent reoccurrence.

     

Have the actions identified been implemented? Yes No

Name of person carrying out this investigation      

Other involved in this investigation      

Signed Date      

Name of senior manager      

Signed Date      

This form must be kept in a secure location to comply with data protection legislation.
Associated documents
List or attach files here.