Incident & Accident Report

Incident / Accident Record
SECTION 1: ACCIDENT / INCIDENT/ NEAR MISS/ DANGEROUS OCCURRENCE DETAILS
LOCATION: DATE OF ACCIDENT

TIME ACCIDENT (24 HOUR
OF
COMPANY / CONTRACTOR:
CLOCK)
EXPECTED RETURN TO WORK
SUPERVISOR IN CHARGE
DATE
SECTION 2: INJURED PERSONS DETAILS

NAME OF INJURED PERSON
AN UPDATE GROUP A
IS THIS PERSON EMPLOYEE: CONTRACTOR
:
ADDRESS
TELEPHONE / MOBILE NO:
OCCUPATION
EMPLOYER:
EMPLOYERS TEL. NO:
IS THE ACCIDENT REPORTABLE TO No Ye

THE HSA? s
REPORTED DATE:
B Y:
WAS THE PERSON AUTHORISED TO WORK IN THE AREA OF THE

INCIDENT?
NAME AND EMPLOYER OF THE SUPERVISOR
SECTION 3: ACCIDENT TAKE A PHOTOGRAPH OF THE SCENE.
TYPE OF ACCIDENT
Fatality Hit something fixed or stationery.
Injured while handling, lifting or
Major injury or condition.
carrying.
Injury resulting in > 3 days absence from Slipped, tripped or fell on the same
work level.
Injury to member of public, require hospital
Fell from height.
treatment.
Did the person become unconscious? How high was the fall? METRES
Did the person need resuscitation? Trapped by something collapsing.
Did the person remain in hospital > 24
Drowned or asphyxiated.
hours?
Exposed to, or contact with, a harmful
Exposed to fire.
substance.
Form 20 - Issue 1 - Apr 16 Page 1 of 7

None of the above. Exposed to an explosion.
ABOUT THE ACCIDENT

Contact with electricity or electrical
Contact with moving machinery.
discharge
Contact with material being machined. Injured by an animal.
Hit by moving vehicle. Physically assaulted by a person.
Hit by moving, flying or falling object. Hit by moving vehicle.
SECTION 4: DETAILS OF INJURY
HEAD CHEST
EYES BACK
NOSE STOMACH
JAW HIP
CHIN RECTUM
NECK THIGH
SHOULDER KNEE
UPPER ARM SHIN
ELBOW ANKLE
LOWER ARM FOOT
WRIST TOE
RIGHT
HAND
SIDE
FINGER MIDDLE
LEFT
THUMB
SIDE
SECTION 5: WITNESSES
WITNESS - 1
ADDRESS
TEL. NO.
EMPLOYER
EMPLOYERS TEL. NO.
WITNESS - 2
ADDRESS
TEL. NO.
EMPLOYER
EMPLOYERS TEL. NO.

SECTION 6: DETAILS OF THE ACCIDENT / INCIDENT / NEAR MISS /DANGEROUS OCCURRENCE
Provide details of the Accident / Incident / Near Miss; events leading up to the Accident /
Incident / Near Miss and follow-up, including First Aid and treatment given.
Please provide a sketch of what happened. Include any measurements, floor level, etc.

SECTION 7: ENVIRONMENT, PLANT AND MAINTENANCE DETAILS
Y N
Was there sufficient natural lighting?
What were the weather conditions at the time?
Was the road surface slippery or wet?
Was a traffic control system in operation?

If yes, provide a sketch.
Who was responsible for the traffic management

system?
Was plant and machinery involved?
What was the make, model, registration number / serial

number?
Was the plant or equipment hired?
Name and address of owner / hire company.
Contact telephone number.
Did the hire company provide operating manuals?
Did the hire company supply any maintenance

Schedules /
Certificates? If yes, provide copies.
Did the hire company provide any training?
Was the equipment serviced / maintained?

If yes, provide details.
Date of last Thorough Examination. (Provide a copy of

the Cert).
Was the work supervised?
Name and Employer of the Supervisor.
Were chemicals involved?
If yes, which chemicals?
Was there damage to the plant or equipment?
Was there damage to property?
Describe the damage
Cost of repair. (Provide copies of Quote / Invoice)

SECTION 8: TRAINING
Y N
Did the injured person receive an
If yes, on which date?
induction?
Did the injured person receive a

copy of :
Method Statement/Work Plan? If yes, on which date?
Risk Assessment? If yes, on which date?
Noise assessments? If yes, on which date?
Manual handling assessments? If yes, on which date?
Hazardous substance
If yes, on which date?
assessments?
Provide details of other relevant

training.
SECTION 9: PERSONAL PROTECTIVE EQUIPMENT

Tick to indicate the personal protective equipment worn by the injured person.
SECTION 10: ENCLOSURES

Details of information enclosed with initial investigation, where relevant.
Y N Y N
Photographs Material Safety Data Sheets
Copies of induction training register Witness statements
Copies of job specific training
Details of training
register
Copies of risk assessments Sketches
Copies of hazardous substance
Insurance claim form
assessments
Copies of noise assessments Estimates for repair
Copies of manual handling
HSA notification & reference
assessments

SECTION 11: PREVENTION OF RECURRENCE
RESPONSI DUE CLOSE

PREVENTIVE ACTIONS TO BE TAKEN (Where Applicable) DATE
BLE DATE D BY
Does this incident provide impetuous to review Risk Assessment? Yes

No
REVIEW
LIST OF RISK ASSESSMENTS
DATE
NAME OF PERSON COMPLETING THE FORM:

_____________________________________________________________
POSITION: _____________________________________________________________

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Incident / Accident Record

SECTION 1: ACCIDENT / INCIDENT/ NEAR MISS/ DANGEROUS OCCURRENCE DETAILS

LOCATION: DATE OF ACCIDENT

SECTION 2: INJURED PERSONS DETAILS

TELEPHONE / MOBILE NO:

EMPLOYERS TEL. NO:

IS THE ACCIDENT REPORTABLE TO No Ye

WAS THE PERSON AUTHORISED TO WORK IN THE AREA OF THE

NAME AND EMPLOYER OF THE SUPERVISOR

SECTION 3: ACCIDENT TAKE A PHOTOGRAPH OF THE SCENE.

Form 20 - Issue 1 - Apr 16 Page 1 of 7

ABOUT THE ACCIDENT

SECTION 4: DETAILS OF INJURY

EMPLOYERS TEL. NO.

EMPLOYERS TEL. NO.

Form 20 - Issue 1 - Apr 16 Page 3 of 7

Form 20 - Issue 1 - Apr 16 Page 4 of 7

What were the weather conditions at the time?

Was the road surface slippery or wet?

Was a traffic control system in operation?

Who was responsible for the traffic management

Was plant and machinery involved?

What was the make, model, registration number / serial

Was the plant or equipment hired?

Name and address of owner / hire company.

Contact telephone number.

Did the hire company provide operating manuals?

Did the hire company supply any maintenance

Did the hire company provide any training?

Was the equipment serviced / maintained?

Date of last Thorough Examination. (Provide a copy of

Was the work supervised?

Name and Employer of the Supervisor.

Were chemicals involved?

If yes, which chemicals?

Was there damage to the plant or equipment?

Was there damage to property?

Describe the damage

Cost of repair. (Provide copies of Quote / Invoice)

Form 20 - Issue 1 - Apr 16 Page 5 of 7

Did the injured person receive a

Method Statement/Work Plan? If yes, on which date?

Risk Assessment? If yes, on which date?

Noise assessments? If yes, on which date?

Manual handling assessments? If yes, on which date?

Provide details of other relevant

SECTION 9: PERSONAL PROTECTIVE EQUIPMENT

SECTION 10: ENCLOSURES

Form 20 - Issue 1 - Apr 16 Page 6 of 7

RESPONSI DUE CLOSE

Does this incident provide impetuous to review Risk Assessment? Yes

NAME OF PERSON COMPLETING THE FORM:

Form 20 - Issue 1 - Apr 16 Page 7 of 7

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