Incident Accident Form
Incident Accident Form
Incident Accident Form
Did the accident or incident require reporting to the authorities? (Include Yes No
any report to the emergency services or the enforcing authorities.)
Has the site of the accident been made safe for the investigation team? Yes No
Attach any additional information, statements, photographs, and enforcing authority report, etc to this
document as appendices.
Details of the accident or incident
Description (Provide a summary of events leading up to the accident or incident with details of the
circumstances immediately prior to the event plus working conditions — weather, visibility, temperature,
housekeeping standards, unusual working conditions, etc.)
Were there any injuries sustained? Yes No
Briefly describe what the injured person was actually doing at the time of the accident or explain the
circumstances leading up to the incident
List any risk assessments undertaken for the activity involved in the accident or incident. (Include
reference numbers, dates of assessment and review, appropriate control measures required, etc; copies
of relevant risk assessments should be made available for examination.)
Explain how the findings of risk assessments had been explained to the workforce.
Was the procedure being followed prior to the accident or incident? Yes No
Environment — were there any environmental conditions that may have had a bearing on the accident or
incident (eg adverse weather, wind, sunlight, rain, poor lighting, wet floor, etc)?
Was any protective clothing and equipment required, was it available and was it in use? (Give details.)
Were any safety devices required, were they available and in use? (Give details.)
Was any equipment or machinery involved? (Name of equipment or machinery, part of equipment or machinery
causing injury, was the equipment or machinery in motion and were there any faults found with the equipment or
machinery or its guarding, had planned guard checks been carried out where applicable?)
This form must be kept in a secure location to comply with data protection legislation.
Associated documents
List or attach files here.