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Accident / incident report form

Name

Position

Date

Time

1 - Date of incident

1.1 - Time of incident

1.2 - Exact location

1.4 - Type of incident

Injury

Near mess

Property damage

Dangerous occurrence

Other

Short answer

2 - Person involved

2.1 - Job / title

2.2 - Contact details

2.3 - Details (Body part affected, minor, serious, fatal etc)

3 - Description of incident

3.1 - What activity was being carried out

3.2 - Was there supervision

3.3 - Environment conditions

3.4 Other details (events leading up to the incident)

4 - First aid given?

4.1 - If so by whom?

4.2 - Emergency services contacted?

4.3 - Any actions taken to make area safe

5 - Witness details

6 - Equipment / substance involved

7 - Risk assessment and contributing factors

8 - RIDDOR Assessment (is the incident RIDDOR reportable?)

8.1 - Type

Human error

Equipment failure

Lack of training

Unsafe environment

Other

9 - Follow up actions

Any additional comments?

Please check all details are accurate and tick for manager review.

Accident / incident investigation form

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