Accident/Incident Report and Investigation

Surname Forenames Pay/Wage Number DOB Age Occupation/Job Title Dept/Employer

Home address
Personal
Details
Date and time of accident Date and time reported Time started work Time finished work

Nature of Injury Other Health/Injury Observations Has the casualty consumed:

1. alcohol or 1. Yes No

2. medication? 2. Yes No

First aid Sent home Referred to G.P. Referred to Occ. Health

Sent to hospital Health centre Work with restrictions Other

Fatal Major injury Disabling injury Occupational illness
Injury Details
and Treatment Minor Injury Lost time Damage only if damage, state what below

Head Eye Trunk Back

Arm Hand Finger Leg
Foot Internal Multiple Hearing
Struck by Struck against Trip Fall from height
Machine Vehicle Substance Burns/scald
Electrocution Hand tool Respiratory Other
Explain clearly how the accident occurred

Account of the
Incident

First aider’s signature Injured person’s signature

Name and address of witness Name and address of witness

Witnesses
Was there a safe Was the person trained Was the safe system
Yes
system of work for Yes No in the system of work? Yes No followed?
No
this job/task?
Was a permit Was the relevant permit Was the person
Yes
Controls necessary for this Yes No issued? Yes No authorised to do the
No
job/task? work?
Was the person Was the person wearing Was the job/task
Yes
experienced in the Yes No the prescribed P.P.E.? Yes No authorised/supervised?
No
job?
Unsafe use of tools/equipment Rendering guards/safety devices P.P.E. not provided
Failure to wear P.P.E. inoperable Inadequate lighting
Unsafe Acts Unsafe position/posture Horseplay Unsafe access/egress
Safe System of Work not followed Tampering Poor environment/temperature
and Unsafe Operating without authority Defective tools/equipment/substances extremes
Conditions Operating at unsafe speed Inadequate guards/safety devices Poor job/task design
Using unsafe tools/equipment Poor housekeeping/stacking Distractions
Unsafe design/construction
Poor personnel selection Inadequate engineering standards Wear and tear
Inadequate training/information Inadequate maintenance/repairs Poor weather conditions
Inadequate tools and equipment Inadequate safety inspections Substandard materials/substances
Contributory Inadequate purchasing standards Poor company culture Production pressures/costs
Factors Inadequate job/task design Poor housekeeping/congestion Inadequate contractor controls
Inadequate safe system of work Excessive noise/vibration Inadequate supervision/leadership
Improper modifications/substitution Poor workstation design/layout Inadequate emergency measures
Mechanical/electrical failure Inadequate spare parts Low safety profile
Lack of knowledge/skill Fatigued/incapacitated Alcohol or medication use
Poor motivation/attitude Peer group pressure/approval Failure to appreciate risks
Personal Avoiding discomfort Illness/stress/physical problem Failure to plan
Factors Wilful deviation from Attempt to gain or save time Carelessness/boredom
instructions/SSOW
1
 Review personnel selection Improve communication Retrain others
Review job/task training Post warnings/signs Improve tools and equipment
Conduct risk assessment Install guards/safety devices Improve selection of contractors
Recommendations Revise/develop SSOW Implement worker/job observation Improve worker attitudes
Implement permit to work Improve maintenance/repairs Review issue of PPE and wear rate
Improve job/task design Revise safety inspections/monitoring Improve housekeeping/work
Retrain/reinstruct Review materials/substances environment
Detail the recommendations to prevent a recurrence

Summary of
Recommendations

Manager Comments
and Approval

Manager’s signature Date

Action By when Date completed

Implementation of
Recommendations

Action By whom Frequency date

Review of Action
Taken

Reviewed by safety committee Chairman’s signature Date

Safety Chairman
Is this incident notifiable to the HSE under RIDDOR? Yes No
RIDDOR Has form F2508 been
sent? Yes No When? By whom?
Approximately what has this accident cost? £
Costs
Signature of investigating manager Signature of Exec. (safety)