Template Information
Category: construction
Template Questions
- Date & Time of Incident Date
- Location of Incident Address
- Please add a photo(s) of the exact area if possible.
- Incident Type (select all that apply)
- Name of on-duty Manager, Assistant Manager at time of incident?
- Incident Details
- Fatal: Work-related death;Major injury/ill health: (as defined in RIDDOR, Schedule 1), including frac
- Describe what happened. Please be detailed but state only facts.
- What were the weather / environmental conditions at the time of the incident?
- Please document all people involved in this incident
- Full Name
- Induction number
- Contact phone number
- What is this person's relation to the incident? (select all that apply)
- Please describe this person's involvement with the incident, including all relevant information
- Attach any relevant photos regarding this person
- Person
- Type of injury or illness? (select all that apply)
- Parts of body affected? (select all that apply)
- Describe this injury or illness
- What was the cause of this injury or illness?
- Please add photos on injuries if possible.
- Tier one manager Sign Off
- Name & Signature of Investigator
- Name of tier 2 manager who has been made aware of the incident.
- What were the contributing factors to this incident occurring? (select all that apply)
- Root Cause Analysis / Contributing Factors
- Corrective Actions
- Name and position of Tier one manager
- Tier one management Sign Off
- Name and position of Tier two manager
- Comments following the incident including a review of current and proposed controls.
- Name and signature of tier two manager.
- Which of the following do you need to attach to this report to accuractly document this incident?
- Please log all relevant evidence below
- Evidence Name and Description
- Evidence ID number (if applicable)
- Evidence and Attachments
- Photos of evidence (if applicable)
- Please detail any further information regarding this evidence (if applicable)
- Please log all relevant vehicle details below
- Vehicle Name and Make
- Vehicle Model
- Vehicle Registration
- Driver (if applicable)
- Photos of equipment (if applicable)
- Please detail any further information regarding this vehicle (if applicable)
- Please log all relevant damage details below
- Damage description
- ID number (if applicable)
- Photos of damage (if applicable)
- Please detail any further information regarding this damage (if applicable)
- Please log all relevant details of other items below
- Item description
- Photos of item (if applicable)
- Please detail any further information regarding this item (if applicable)
- Please log all relevant equipment details below
- Equipment Name and Make
- Equipment Model
- Equipment ID number (if applicable)
- Please detail any further information regarding this equipment (if applicable)
- Due to the severity of the incident a meeting must be scheduled to ensure all areas have been reviewe
- Name of SMT member reviewing the incident.
- Date and time of meeting. Date
- Please give details of the meeting including - all people present - Thoughts of the SMT member - a review of the root cause analysis - review of further controls/actions required including people responsible and timescales.
- Name and signature of SMT member.
- Name of MD and SMT members reviewing the incident.
- Name and signature of MD.