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

Incident / Accident Record
None of the above. Exposed to an explosion.

ABOUT THE ACCIDENT

Contact with moving machinery.
Contact with material being machined.
Hit by moving vehicle.
Hit by moving, flying or falling object.
Contact with electricity or electrical
discharge
Injured by an animal.
Physically assaulted by a person.
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
Form 20 - Issue 1 - Apr 16 Page 2 of 7
Incident / Accident Record

EMPLOYERS TEL. NO.

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

 Incident / Accident Record
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.

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

Incident / Accident Record
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)

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

 Incident / Accident Record
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

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

 Incident / Accident Record
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: _____________________________________________________________

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