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Accident-Incident Report Form

This document is an accident/incident investigation report form containing sections to document an accident/incident. Section A requires details on the injured person, location, and nature of injury/damage. Section B describes the incident, cause, immediate response, and prevention proposals. Section C is a risk assessment matrix to determine the risk rating and category.

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mujahid_islam85
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388 views3 pages

Accident-Incident Report Form

This document is an accident/incident investigation report form containing sections to document an accident/incident. Section A requires details on the injured person, location, and nature of injury/damage. Section B describes the incident, cause, immediate response, and prevention proposals. Section C is a risk assessment matrix to determine the risk rating and category.

Uploaded by

mujahid_islam85
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
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Download as DOC, PDF, TXT or read online on Scribd
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Accident / Incident Investigation Report

(REV 6/May 2014)


Type of *Accident / **Incident (Mark ‘X’ in the box as appropriate)
*Accident = An incident which caused personnel injury, illness and/or damage (loss) to assets, the environment or third party
**Incident = An unplanned and undesired event that may result in loss (Accident) or had the potential to do so (Near Miss)
Accident Near Miss

Personal Injury Environmental / Property Damage

Manager / Supervisor MUST Ensure ALL Sections of Part A are Complete


PART A
Originator / Injured Person Position Date of Incident Time of Incident

Length of Service Age Employee (Mark ‘X’ in the box as appropriate)


Visitor (Mark ‘X’ in the box as appropriate)
Contractor (Mark ‘X’ in the box as appropriate)
Department Contract Company

Address
Part Number

Project Name
Location of Incident Object / Equipment / Substance Involved

Nature of Injury Nature of Damage/Environmental Release

Description: Describe clearly how the incident occurred, including time line. State what the injured person was doing at the time. Attach a sketch,
measurements, and photographs if required. Indicate the immediate cause of the accident.

Weather Conditions (if appropri


ate):
Analysis: What acts, failures to act or conditions contributed to this incident?

Immediate Response: What actions were taken, i.e. area made safe, first aid administered, area cordoned off, photos taken, measurements
taken, witness statements taken, management informed etc.

Prevention: What action is proposed to prevent recurrence?


Risk Rating
(Use Corporate risk matrix to determine. Matrix found on the HSE Reporting SharePoint site)
Likelihood of re-occurrence (1- Severity of incident
Total (L x S) (1-25)
5) (1-5)
Manager/Supervisor: Print Name: Signature: Date:

Injured Person / Print Name: Signature: Date:


Person Reporting
Incident:
Follow up / Review / Close Out
PART B
HSE Group response / actions raised:

HSE Investigation required: Recordable YES NO Report No.


YES/NO RIDDOR
Investigation Owner SEPA
Corporate
Work Related Ill-Health
Supervisor Response/action close out:

Final Corporate Risk Matrix Review


(Use Corporate risk matrix to determine. Matrix found on the HSE Reporting SharePoint site)
PART C
Likelihood of re-occurrence Severity of incident
Total (L x S) (1-25)
(1-5) (1-5)
Category Green / Yellow / Red

Occupational Health Nurse


Comments:

Print Name: Signature: Date:


HSE Group Member

Print Name: Signature: Date:


Occupational Health Nurse
(only if health related)
Print Name: Signature: Date:
HSE Chairman

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