Version:
Page:
Issue Date:
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10 November 2001
ACCIDENT / INCIDENT INVESTIGATION
LOCATION
Section
Building
TIME OF OCCURRENCE
Date
Time
Day of week
INVESTIGATION DATE
Date
Time
Day of week
INVESTIGATION TEAM
BRIEF DESCRIPTION OF INCIDENT
NAMES OF PERSONS INVOLVED (NOTE ANY INJURED PERSONS)
Surname
Given Name
Job Title
Section
Job Title
Section
NAMES OF WITNESSES
Surname
Given Name
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10 November 2001
ACCIDENT / INCIDENT INVESTIGATION
SEQUENCE OF EVENTS LEADING UP TO OCCURRENCE
1.
2.
3.
4.
5.
6.
7.
8.
ACTIONS TAKEN AT TIME OF OCCURRENCE TO MINIMISE IMPACT
(EMERGENCY PROCEDURES, EQUIPMENT REMOVAL, ETC.)
1.
2.
3.
4.
5.
DESCRIPTION OF LIGHTING, NOISE, VISIBILITY CONDITIONS AT TIME
VARIATIONS FROM SOP’S OR STANDARD PRACTICE
DETAILS OF ANY IDENTIFIED MANAGEMENT SYSTEM DEFICIENCIES
CONTRIBUTING TO OCCURRENCE
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Issue Date:
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10 November 2001
ACCIDENT / INCIDENT INVESTIGATION
LIST OF ATTACHMENTS TO REPORT (PHOTOGRAPHS, RISK ASSESSMENTS, STATEMENTS,
ETC.)
1.
2.
3.
4.
RECOMMENDED CORRECTIVE ACTIONS
1.
2.
3.
4.
5.
MANAGEMENT AGREED CORRECTIVE ACTIONS
Item no.
1.
2.
3.
4.
5.
Responsibility
Target Date
Completed
Managers Name
Managers Title
Signature
INVESTIGATION TEAM
Name
Signature
Date
Date for Review
Review Carried out by
Date Review Completed
FILING
Attach copy to injury/illness/incident report
Copy to Section Manager
Copy to OHS Chairperson
Copy to Human Resources Section
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