Accident reporting form

A: Injured person details

TitleFamily name(Required)Other namesGender(Required)Please select an optionMaleFemaleNon-binaryTransgenderIntersexI prefer not to sayDate of birth(Required)

DD slash MM slash YYYY
AddressJob title(Required)Project manager (if applicable)Line managerTelephone number(Required)Email(Required)

B: Accident details

Date accident form completedDate of accident

DD slash MM slash YYYY
TimeAddress(Required)Location(Required)Activity at the time of incident(Required)Description of incident(Required)Nature & extent of injuries(Required)

C: Acceptance

Job titleDatePhoneEmail(Required)

This form is to be used by the Investigation Officer, or person on site responsible for the casualty’s welfare, to conduct an investigation, which will involve an analysis of all the information available, physical (the scene of the incident), verbal (the accounts of witnesses) and written (risk assessments, procedures, instructions, job guides etc), to identify what went wrong and determine what steps must be taken to prevent the adverse event from happening again, initiating the escalation process as appropriate, to Management or the HR Department.

Gathering the information

Where, when and who?

Where and when did the adverse event happen? Were there any witnesses?Who was injured / suffered ill health or was otherwise involved with the adverse event?

How and what?

How did the adverse event happen? Note any equipment involved.What activities were being carried out at the time?Was there anything unusual or different about the working conditions?Were there adequate safe working procedures and were they followed?Was the risk known? If so, was a Risk Assessment completed? (Please indicate details of the Risk Assessment & who conducted it)Who was injured / suffered ill health or was otherwise involved with the adverse event?Were the people involved competent and suitable?Was the safety equipment sufficient?What were the immediate, underlying and root causes?

Outcome – next steps, key learnings, change to process, etc.

As you selected 'violation', what is recommended?As you selected 'escalation', what is recommended?Additional comments

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Person completing this final accident report form

Job titleEmail(Required)

Date
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