Accident Investigation Form

7/27/2019 Accident Investigation Form

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{Company Name} Accident Investigation Form

Document No: Number of sheets included:

Part A – Details of Affected Person

Reference number:

Sex: (M or F)

Age:

Employee: Self Employed:

Any other person (contractor/public):

PART B – Notification

Tick appropriate box(es)

Fatality Major injury Over 3-day

Dangerous occurrence Minor injury

Is it RIDDOR1 reportable? Yes No

If yes, attach copy of RIDDOR to this report.

First aid: Yes No Doctor: Yes No

Ambulance: Yes No

Hospitalised: Yes No

Part C - Details of Incident

Date of incident: Time:

Where did the incident take place?

1 Reporting of Injuries, Diseases and Dangerous Occurrence Regulations – RIDDOR. Find further guidance atHSA09083

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Type of incident:

What was the injury?

(what part of the body was injured/affected?)

If first aid or other treatment was given please provide details below:

Part D – Investigation

Describe what happened




(Additional information can be added to a separate page)

Photographs/drawings/sketches? Attach and indicate below:

Photographs:

Negative: Digital: Polaroid:

Drawings/sketches:

Person providing visuals:

Date:

Describe significant factors:


Separate sheet may be used



Actions required:

Actions implemented

Part E – Responsible Person Completing Report

Name:

Position:

Signature: Date:

Director/Manager :

Name:

Position in Company:

Signature: Date:

Part F - Witness Statements




Witness name:

Address:

Telephone:

Additional witnesses should be added to the witness list

Witness statement:

Ensure all witness statements and continuation sheets are attached.




Accident Investigation Form Guidance Notes

This form is only to be used where an accident/incident has caused that person to beabsent from work.

Accident investigation and identifying the cause is a vital aspect of the company’smanagement of health and safety. Details on the form are confidential and access isrestricted to the company’s management, safety representatives, insurance companyand the regulating authorities.

Part AThis part must be completed so that the details are available if the injured party needsto be located at some point in the future. The information may be required by theinsurance company and the relevant regulatory authority.

Part B

If there is a serious accident/incident, there may be a requirement to complete aRIDDOR2 form.

Part CDetails of the location of the accident/incident must be provided. The type of accident/incident should be recorded, for example 'fall from height' or 'trapped bymachinery'. A description of the injury and the part of the body involved, for example'cut to head' or 'injury to left leg'.

The date and time of the accident/incident must be recorded.

Full details of the accident/incident should include the location, time and type of incident. If appropriate, also include failure of equipment, weather and lightingconditions. These are examples and every incident will identify different failures.

Provide a description of any form of treatment and details of who provided thetreatment.

Part D A full and detailed description of what occurred must be made including those whowitnessed the accident/incident. This section should be completed as soon after theaccident/incident as possible. It is important that all information is factual.

To support the investigation photographs/sketches are often of value as a visualrecord. The type of photograph e.g. film, digital, video, Polaroid should be recorded asshould the name and date of the person undertaking the visual image.

Any significant factors should be included. This could include details such asmaintenance records, date of last inspection, date of last safety meeting etc.

The results of an accident/incident will identify remedial actions. These should berecorded with time frames for implementation.

2 Reporting of Injuries, Diseases and Dangerous Occurrence Regulations – RIDDOR. Find further guidance atHSA09083




As a follow up to the actions required, the information should be recorded as soon asthe actions are completed providing details and dates.

Part EThis part must be completed in full.

Part FWitnesses are important to any investigation to determine what occurred. Name,address and telephone number must be included. This information should be held inconfidence. Additional pages can be used if required. A witness making a statementmust sign and date each page and no gaps should be left at the end of the text toavoid comments being added.


Documents

Accident Investigation Form