Incident Investigation Report

Note: This form is to be used to conduct a formal incident investigation

Project number

Project Name

Client

Business Line

Practice Line

Base office/Country

Injured Person
Name

Date of birth

Age

Home address

Occupation

Accident
Date

Time

Location
Work processes
involved

Cause

Details of injury

Person reporting accident

Name

Home address

Occupation

Signature

Date of report

Without prejudice Attorney / Client privilege

Document Reference Number: ORG1-06-002-MOD-TS0-0-PRM-TEM-2820-00

Revision Number: 00
Date: 05 January 2020
 Incident Investigation Report
Company/Subsidiary
involved

Location of incident

Date of incident

Time of incident

MODON role on the

project?

MODON responsibility
for Safety?

Do we have a Safety
Manager on site?

Personal Injury Disease / Illness Property damage

Nature of incident
Near miss Environment spill / release Dangerous occurrence

Fatality Medical Treatment case Restricted work case

Severity (select one)
First Aid only Days away from work case
Probability of Probable Likely Possible
recurrence
(select one) Unlikely Rare

Description of how incident occurred

Without prejudice Attorney / Client privilege

Document Reference Number: ORG1-06-002-MOD-TS0-0-PRM-TEM-2820-00

Revision Number: 00
Date: 05 January 2022
Form Page 2True7
 Immediate causes: What unsafe acts or conditions caused the event?

Secondary causes: What human, organisational or job factors caused the event?

Remedial actions: Recommendations to prevent recurrence

Investigator Name Signature Date

Without prejudice Attorney / Client privilege

Document Reference Number: ORG1-06-002-MOD-TS0-0-PRM-TEM-2820-00

Revision Number: 00
Date: 05 January 2022
Form Page 3True7
 Follow up action/review of recommendations and progress

Name of reviewer Position/ title of reviewer Signature of reviewer Date

Without prejudice Attorney / Client privilege

Document Reference Number: ORG1-06-002-MOD-TS0-0-PRM-TEM-2820-00

Revision Number: 00
Date: 05 January 2022
Form Page 4True7
List of additional documentation supporting this report

Key: M = mandatory A = if applicable D = desirable

Document Reference Key Tick Document Reference Key Tick

Site induction M Contract safety plan M

Sub contract pre-order,

Site induction briefing
M including procurement A
record
strategy

Client/ management/
A Method statement M
visitor induction

Training record/ Method statement

A M
certificates briefing record

Plant test certificates A Risk assessment A

Risk assessment
Plant operators licence A A
briefing record

Maintenance/ service Minutes of safety

A M
records meetings

Minutes of supervisors
Toolbox talks record A D
safety meeting

Improvement/
Accident book M prohibition notices A
served

Photographs
D Medical records A
(annotated & signed)

Permits issued A Drugs & alcohol test A

PPE issue record A Site location drawings A

Witness Task drawings/

Witness statements M A
Statement diagrams

Site safety audit

Tape/video footage A A
reports

Samples of hazardous
Special contract
A materials, A
conditions
contamination etc.
Air quality, noise
Tender safety plan A levels, environmental A
records etc.

Note: Please tick as appropriate for those items above included in this report.

Without prejudice Attorney / Client privilege

Document Reference Number: ORG1-06-002-MOD-TS0-0-PRM-TEM-2820-00

Revision Number: 00
Date: 05 January 2022
Form Page 5True7
 Sketch of area at time of incident

Without prejudice Attorney / Client privilege

Document Reference Number: ORG1-06-002-MOD-TS0-0-PRM-TEM-2820-00

Revision Number: 00
Date: 05 January 2022
Form Page 6True7
Document Reference Number: ORG1-06-002-MOD-TS0-0-PRM-TEM-2820-00
Revision Number: 00
Date: 05 January 2022
Form Page 7True7