Accident & Incident Investigation Form

Incident Investigation Form
Section 1: Overview
Name of Injured Person(s) Date of Incident
Manager carrying out Date of Investigation
investigation
Incident Severity (from HSI01 Catastrophic ☐
form)
Major ☐
Moderate ☐
Minor ☐
Insignificant ☐
Near miss ☐
Body Map Abrasion / Bruising

This section MUST be
completed. Amputation
If no injury or damage Asphyxiation / poisoning

occurred, record the Burn / scald
incident as a near miss
Concussion / internal injuries
with no injury.
Dislocation
Where there is more
Electric Shock
than one injury, place a
number on the part of Fracture
the body affected and Lacerations / cuts
put the same number in
Loss of Sight / eye damage
the type of injury.
Continue until all of the Multiple Injuries
injuries are listed. Natural Causes
Penetrating Injury
Respiratory distress
Sensitisation / irritation
Shock / stress
Sprain / strain
Superficial Injury
Other (please specify below)
Section 2: Investigation Information Gathering

1. Where and when did the incident happen? Include building and room. For outside areas consider aerial map with site of
incident marked.
2. Who was injured/ suffered ill health or was otherwise involved with the incident?
Include name , length of service, status .
3. Were there any witnesses to this incident?
Yes ☐ No ☒
3.1 Have witness statements been taken?
Yes ☐ No ☒
Supporting documents included in this investigation:
☐ witness statements - Name(s)
☐ Other (Please state)
4. How did the incident happen? (Be as detailed as possible)

(What activities were being carried out at the time and any equipment involved including make, model, serial no)
Supporting documents/items included in this investigation:

☐ Photographs
☐ CCTV or video/audio files
☐ Plans
☐ Physical evidence e.g. whole of damaged parts of equipment, samples of substances, clothing or footwear
☐ Manufacturers/suppliers user guides
☐ Results of tests e.g. dust or noise monitoring
☐ Health surveillance records
☐ Best practice guidance e.g. trade association or Health and Safety Executive guidance
☐ Other (Please state)
5. Why did the incident happen? (Use the Five Why’s technique to identify root causes)
6. Was there a risk assessment and/or safe operating procedure (SOP) for the task? Yes ☐ No ☐
6.1 Did the risk assessment/SOP cover all aspects of the task? Yes☐ No ☐
6.2 Was it being followed? Yes☐ No ☐
6.3 Supporting documents/items included in this investigation :
☐ Risk assessment(s) e.g. COSHH, Manual Handling, LOLER
☐ Safe operating procedures
Give Details:
7. Was there anything unusual or different about the working conditions at the time of the incident? e.g. weather, open day
etc.
Yes ☐ No ☐
Give details:
8. What injuries or ill health effects, if any, were caused?
9. Was maintenance, cleaning or housekeeping sufficient?

Yes ☐ No ☐
9.1 If not, explain why not:
Supporting documents/ items included in this investigation:

☐ Maintenance Records ☐ Other (Please state)
☐ Cleaning records
Give Details:
10. Was a lack of competency/training a factor in this incident?
Yes ☐ No ☐
10.1 Give details:
Supporting documents/items included in this investigation:

☐ Training records
☒ Other (Please state)
11. Did the workplace layout influence the incident?

Yes ☐ No ☐
11.1 How did the workplace influence the incident? e.g. maintenance, routine/non-routine work being completed
12. Was safety equipment and/or personal protective equipment provided?

Yes ☐ No ☐
12.1 Was the equipment suitable for the task and being used correctly?
Yes ☐ No ☐
Give details:
12.2 Was PPE used during the task?
Yes ☐ No ☐
12.3 Was PPE compatible with other PPE used?
Yes ☐ No ☐
13. Are you aware of any similar incidents?
Yes ☐ No ☐
Give details:
14. Is there any other information not detailed above that is relevant to this incident?
Yes ☐ No ☐
Give details:
Section 3: Action Plan and Investigation
N Description Allocated Target Comments Task Date

o to Date Complete Completed
1 ASAP Yes No
☐ ☐
Yes No
☐ ☐
Yes No
☐ ☐
Yes No
☐ ☐
Yes No
☐ ☐
Yes No
☐ ☐
Yes No
☐ ☐

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Accident & Incident Investigation Form

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Incident Investigation Form

Body Map Abrasion / Bruising

If no injury or damage Asphyxiation / poisoning

Other (please specify below)

Section 2: Investigation Information Gathering

3. Were there any witnesses to this incident?

4. How did the incident happen? (Be as detailed as possible)

Supporting documents/items included in this investigation:

8. What injuries or ill health effects, if any, were caused?

9. Was maintenance, cleaning or housekeeping sufficient?

Supporting documents/ items included in this investigation:

10. Was a lack of competency/training a factor in this incident?

10.1 Give details:

Supporting documents/items included in this investigation:

11. Did the workplace layout influence the incident?

12. Was safety equipment and/or personal protective equipment provided?

N Description Allocated Target Comments Task Date

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