Health Safety and Environmental Management Procedures Manual

Title: HS&EP 5 Issue No. 02 Revision: 00

Controlled Copy Page: 8 of 10

ACCIDENT/INCIDENT INVESTIGATION REPORT

REPORT NUMBER: SITE: DATE

A. INCIDENT DETAILS :
INCIDENT EFFECT:
INCIDENT CATEGORY:
MAJOR___ SERIOUS___ MINOR___
AREA OF INCIDENT:
LOST TIME_____ NON LOST TIME_____ NON-INJURIOS_____
NEAR MISS_______(NO DAMAGE/LOSS)_______
INCIDENT POTENTIAL:
MAJOR___ SERIOUS____ MINOR ____
DEPT: SUPERVISOR:

DATE AND TIME OF INCIDENT: EXACT LOCATION:

OPERATION: ACTIVITY: EQUIPMENT INCIDENT TYPE

DESCRIPTION OF INCIDENT:

B. DETAILS OF INJURED PERSON:

DATE OF BIRTH: TIME INTO SHIFT: MALE/FEMALE RETURN TO WORK
Y/N
NATIONALITY: EXPCE IN JOB: EXPCE THIS SITE:

EMPLOYER: COMMENTS:

1ST AIDER:

C. WITNESSES POSITION/
NAME ADDRESS EMPLOYER
1.

2.

3.

D. INVESTIGATION TEAM
NAME EMPLOYER POSITION
1.

2.

3.

Safety Rep:
IMMEDIATE CAUSE: BASIC CAUSE:

RECOMMENDATIONS/ACTIONS TAKEN TO PREVENT RECURRENCE:

PERSON(S) NAME DEPT: POSITION: SIGNATURE:

RESPONSIBLE FOR
IMPLEMENTATION:
NAME SIGNATURE DATE COMMENTS
ACTIONS COMPLETED
DEPT MANAGER
Use the back of this form for sketches.

13 September 2004 OP 07 Briggs Commercial Limited

Form No. F005A