Version #001.
ACCIDENT INVESTIGATION REPORT
Accident Investigation Report
NOTE: A separate form should be completed for each person injured.
This investigation is aimed at identifying causes, not attributing blame.
Reference No. _____________ Injury Damage Near miss
1. DETAILS OF INJURED PERSON
Surname First Name Other Initials
Date of Birth Gen
Day Month Year m/f Preferred Language Contact No.
Occupation/Job Title & Details:
Experience in job Position Years / Months
Main Tasks performed Training provided: Induction.
Trade/task specific.
Both of the above.
Neither of the above
2. DETAILS OF INCIDENT
Time & Date of Damage/Acc/Near Miss: Time & Date Report Received:
Date: Date:
Time: AM/PM Time: AM/PM
Location: ________________________________________________________________________________________________
Include project site if applicable
Accident Results:
Fatal Hospital Doctor Only Emergency Dept.
First Aid Only Property Damage Nil (Injury/Damage)
3. DETAILS OF INJURY
Nature of injury, disease or damage:
New Injury Recurrent Injury Aggravated Injury
Other:
Leading Plumbing Solutions - ACCIDENT INVESTIGATION REPORT
Version #001.0
Specifics of the actual injury:
_______________________________________________________________________________________
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_________________________________________________________________________________________________________
Bodily locations of injury, disease or damage: _______________________
______________________________________________________
______________________________________________________
______________________________________________________
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4. TREATMENT ADMINISTERED
First Aid given Yes No
First Aider name: _______________________________________________________________________________________ ______________
Treatment: ____________________________________________________________________________________________ ______________
Referred to: ___________________________________________________________________________________________ ______________
5. DID THE INJURED PERSON STOP WORK?
Yes No If yes, state date:____________________ Time:_______________________
Outcome:
Treated by doctor Hospitalised Workers comp claim Emergency Dept.
Returned to normal work Alternative duties Rehabilitation
Rehabilitation Date of Resumption
Not Required Short-term alternate duties
Required Permanent alternate duties
Normal Duties
Day Month Year
Total number of days lost
Name/s of witnesses Signature of worker Date:
How exactly was the injury, disease or damage sustained? What was the worker doing at the time? (Loading Truck
etc.) Include all contributing factors:
______________________________________________________________________________________________
______________________________________________________________________________________________
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Leading Plumbing Solutions - ACCIDENT INVESTIGATION REPORT
Version #001.0
EMPLOYEE TO COMPLETE THIS SECTION
What (if any) process will eliminate this incident/accident from re-occurring:
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
ADDITIONAL NOTES OR COMMENTS:
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
EMPLOYEE SIGNATURE …………………………………………..……………… Date: ……………………………………………………
SECTION 6-9 MUST BE COMPLETED BY EMPLOYER
Investigating Person:
Name Position Signature
Date investigation conducted:
6. INCIDENT INVESTIGATION (comments to include causal factors):
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
7. RISK ASSESSMENT
Likelihood of recurrence: _________________________________________________________________________________ _______________
Severity of outcome:___________________________________________________________________________________________________
Level of risk: ___________________________________________________________________________________________ ______________
Leading Plumbing Solutions - ACCIDENT INVESTIGATION REPORT
Version #001.0
8. ACTIONS TO PREVENT RECURRENCE
Action By whom By when Date completed
9. ACTIONS COMPLETED
Signed (Manager): ______________________________________________________ Date ________________________
Feedback to person involved Date: __________________________
10. REVIEW COMMENTS
Staff meeting: __________________________________________________________________________________________
Reviewed by Manager (signed): ___________________________________________ Date: __________________________
Reviewed by Injured Employee.(signed): ____________________________________ Date: __________________________
11. ADDITIONAL NOTES OR COMMENTS:
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
Leading Plumbing Solutions - ACCIDENT INVESTIGATION REPORT
