{Company Name} Accident Investigation Form

Document No: Part A Details of Affected Person

Reference number:

Number of sheets included:

Sex:

(M or F)

Age: Employee: Self Employed:

Any other person (contractor/public): PART B Notification Tick appropriate box(es) Fatality Major injury Over 3-day Minor injury Yes No

Dangerous occurrence Is it RIDDOR1 reportable?

If yes, attach copy of RIDDOR to this report. First aid: Yes No No No Doctor: Yes No

Ambulance: Yes Hospitalised: Yes

Part C - Details of Incident Date of incident:

1

Time:

Reporting of Injuries, Diseases and Dangerous Occurrence Regulations RIDDOR. Find further guidance at HSA09083

Where did the incident take place?

Type of incident:

What was the injury?

(what part of the body was injured/affected?)

If first aid or other treatment was given please provide details below:

Part D Investigation Describe what happened

(Additional information can be added to a separate page)

Photographs/drawings/sketches? Attach and indicate below: Photographs: Negative: Drawings/sketches: Person providing visuals: Digital: Polaroid:

Date:

Describe significant factors:

Separate sheet may be used

Actions required:

Actions implemented

Part E Responsible Person Completing Report Name:

Position:

Signature:

Date:

Director/Manager: Name:

Position in Company:

Signature:

Date:

Part F - Witness Statements Witness name:

Address:

Telephone:
Additional witnesses should be added to the witness list

Witness statement:

Ensure all witness statements and continuation sheets are attached.

Accident Investigation Form Guidance Notes This form is only to be used where an accident/incident has caused that person to be absent from work. Accident investigation and identifying the cause is a vital aspect of the companys management of health and safety. Details on the form are confidential and access is restricted to the companys management, safety representatives, insurance company and the regulating authorities. Part A This part must be completed so that the details are available if the injured party needs to be located at some point in the future. The information may be required by the insurance company and the relevant regulatory authority. Part B If there is a serious accident/incident, there may be a requirement to complete a RIDDOR2 form. Part C Details of the location of the accident/incident must be provided. The type of accident/incident should be recorded, for example 'fall from height' or 'trapped by machinery'. A description of the injury and the part of the body involved, for example 'cut to head' or 'injury to left leg'. The date and time of the accident/incident must be recorded. Full details of the accident/incident should include the location, time and type of incident. If appropriate, also include failure of equipment, weather and lighting conditions. These are examples and every incident will identify different failures. Provide a description of any form of treatment and details of who provided the treatment. Part D A full and detailed description of what occurred must be made including those who witnessed the accident/incident. This section should be completed as soon after the accident/incident as possible. It is important that all information is factual. To support the investigation photographs/sketches are often of value as a visual record. The type of photograph e.g. film, digital, video, Polaroid should be recorded as should the name and date of the person undertaking the visual image. Any significant factors should be included. This could include details such as maintenance records, date of last inspection, date of last safety meeting etc. The results of an accident/incident will identify remedial actions. These should be recorded with time frames for implementation.
2

Reporting of Injuries, Diseases and Dangerous Occurrence Regulations RIDDOR. Find further guidance at HSA09083

As a follow up to the actions required, the information should be recorded as soon as the actions are completed providing details and dates. Part E This part must be completed in full. Part F Witnesses are important to any investigation to determine what occurred. Name, address and telephone number must be included. This information should be held in confidence. Additional pages can be used if required. A witness making a statement must sign and date each page and no gaps should be left at the end of the text to avoid comments being added.