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    Inccident Investigation Form v5.0

    Uploaded by

    ahmed
    This 3 page incident report document contains sections for recording details of an incident or near miss event including: type of event, harm caused, employee details, witness details, investigation required, investigation level, and reported by. Page 1 requests event details, injuries/ill health effects, and investigation details such as activities, equipment, working conditions, competence, and causes. Page 2 focuses on causes and recommended risk controls. Page 3 documents the investigation team members, signatures accepting the report, and communication of findings.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Inccident Investigation Form v5.0

    Uploaded by

    ahmed
    113 views4 pages
    This 3 page incident report document contains sections for recording details of an incident or near miss event including: type of event, harm caused, employee details, witness details, investigation required, investigation level, and reported by. Page 1 requests event details, injuries/ill health effects, and investigation details such as activities, equipment, working conditions, competence, and causes. Page 2 focuses on causes and recommended risk controls. Page 3 documents the investigation team members, signatures accepting the report, and communication of findings.

    Original Title

    Inccident Investigation form v5.0 (1)

    Copyright

    © © All Rights Reserved

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    This 3 page incident report document contains sections for recording details of an incident or near miss event including: type of event, harm caused, employee details, witness details, investigation required, investigation level, and reported by. Page 1 requests event details, injuries/ill health effects, and investigation details such as activities, equipment, working conditions, competence, and causes. Page 2 focuses on causes and recommended risk controls. Page 3 documents the investigation team members, signatures accepting the report, and communication of findings.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    113 views4 pages

    Inccident Investigation Form v5.0

    Uploaded by

    ahmed
    This 3 page incident report document contains sections for recording details of an incident or near miss event including: type of event, harm caused, employee details, witness details, investigation required, investigation level, and reported by. Page 1 requests event details, injuries/ill health effects, and investigation details such as activities, equipment, working conditions, competence, and causes. Page 2 focuses on causes and recommended risk controls. Page 3 documents the investigation team members, signatures accepting the report, and communication of findings.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 4

    Incident report Date/time of event

    Company Department Site name

    Type of event Injury Ill health Near miss

    Harm (or potential for harm) Fatal or major Serious Minor Damage to property only
    Employee involved in the event Name Address
    Position
    Contact number

    Brief description of event


    (Details of what happened, when, where, and
    emergency action taken)

    Details of witness(es), if any


    (Name, position, contact number, etc.)

    Investigation required Yes Reportable Yes


    Date/time reported
    Investigation level High Medium Low Minimal
    Priority Entry in accident book Yes
    Leader of investigation Date/time entered

    Reported by Position Date Signature


    Incident investigation report Page 1 of 3

    Company Department Site name

    Event details Employee(s) involved Location


    Date
    Time

    Injuries or ill health effects, if any

    Investigation details
    Include details such as
    - overview of the event
    - activities being performed
    - equipment used
    - working conditions
    - safety of working procedures
    - maintenance
    - competence of people involved
    - workplace layout
    - safety equipment used
    - any other conditions which may have influenced the
    event
    Incident investigation report Page 2 of 3

    Causes of the event


    Immediate causes Underlying causes Root causes

    Which risk control measures should be implemented to prevent recurrence?


    Risk control Planned completion date Actual completion date Manager responsible

    Which risk assessments and safe working procedures need to be reviewed and updated?
    Risk control Planned completion date Actual completion date Manager responsible
    Incident investigation report Page 3 of 3

    Are there any further details that


    should be mentioned?

    Members of the investigation team Name Position Name Position

    Signed on behalf of the investigation team


    Name Position Date Signature

    Report accepted by
    Name Position Date Signature

    The findings of this investigation need to be communicated to the following people


    Name Position Date Signature

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