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Accident and incident investigation report

Author: Novade Solutions

Use this template to investigate the cause and/or contributing factors of an incident, accident or hazard and establish corrective actions to prevent re-occurrence.

Published on: 11/19/2021

Accident/incident investigation report

General Information

Company name

Project title

Location

Contract no.

Report title

Report date

Accident date

Accident ref.

Initial report

Final report

General location of accident/incident

Other

Date of accident

Time

Injured person’sname

Occupation

Address

Employer

Supervisor

Site manager

First aider

Injury

Treatment administered (on or off site)

1. Witness

Employer

2. Witness

Employer

3. Witness

Employer

Incident classification (indicate appropriate category)

Previous experience/training of injured person

Relevanttraining details

Other (specify)

Date ofinduction

Date oflast relevantawareness talk(s)

Supporting information availableDigital photographs must have the correct level of validation (date, independent witness, etc.)

Supporting information available

Other (state below)

*Photographs

Date

Time

Background information (in date/time order, to include – start dates, previous works, contract progress,work group personnel, adjacent trades, nature of work being undertaken, etc.)

Date

Time

Summary of accident (in date/time order, description of the incident including location, personnel involved, activity being carried out, equipment involved, permits to work, sitedrawings and working conditions. Record timeline of events)

Immediate action taken (emergency plan, first aid, site secured, hospital, contacts made, prevention of further loss)

Distribution

Name

Position

Telephone

Dist. ()

Accident/incident investigation report (Part 2)

Immediate cause of accident (consider all factors, including temperature, weather, system failure, design failure, equipmentfailure, poor housekeeping, human error and the influence of alcohol or drugs)

Root cause of accident (consider issues, such as lack of training and awareness, time constraints, communicationand external influences)

Remedial action

Conclusion and recommendations (analysis of evidence, comparison with standards, highlight the main issues,who is responsible, and so on)

Recommendations

Immediate

Interim

Long-term

Learning opportunities and responsibilities

Person responsible

Action

Target date

Close-out date

*Signature

Communication of learning

Other (state)

Appendices

Other report forms

Witness statements

*Photograph index sheet and photographs

Drawings

Training/control

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Accident/incident investigation report

General Information

Company name

Project title

Location

Contract no.

Report title

Report date

Accident date

Accident ref.

Initial report

Final report

General location of accident/incident

Other

Date of accident

Time

Injured person’sname

Occupation

Address

Employer

Supervisor

Site manager

First aider

Injury

Treatment administered (on or off site)

1. Witness

Employer

2. Witness

Employer

3. Witness

Employer

Incident classification (indicate appropriate category)

Previous experience/training of injured person

Relevanttraining details

Other (specify)

Date ofinduction

Date oflast relevantawareness talk(s)

Supporting information availableDigital photographs must have the correct level of validation (date, independent witness, etc.)

Supporting information available

Other (state below)

*Photographs

Date

Time

Background information (in date/time order, to include – start dates, previous works, contract progress,work group personnel, adjacent trades, nature of work being undertaken, etc.)

Date

Time

Immediate action taken (emergency plan, first aid, site secured, hospital, contacts made, prevention of further loss)

Distribution

Name

Position

Telephone

Dist. ()

Accident/incident investigation report (Part 2)

Root cause of accident (consider issues, such as lack of training and awareness, time constraints, communicationand external influences)

Remedial action

Conclusion and recommendations (analysis of evidence, comparison with standards, highlight the main issues,who is responsible, and so on)

Recommendations

Immediate

Interim

Long-term

Learning opportunities and responsibilities

Person responsible

Action

Target date

Close-out date

*Signature

Communication of learning

Other (state)

Appendices

Other report forms

Witness statements

*Photograph index sheet and photographs

Drawings

Training/control