Near miss and aaw investigation checklist
What does this form include?
This form contains 38 sections:
Type of incident
PLEASE COMPLETE ALL FIELDS FULLY AND ACCURATELY
- Is this incident likely to lead to an over 7 day absence?
Time and Date of Incident Date
Where did this happen? Address
Details of Affected Person
- Were there people injured/affected or involved in this Incident?
Name/Tech Number
Category of Person
Involvement
Severity Level
Injury/Illness
Part of Body
Area
Injury Assessment
Injury Comments
Was treatment given?
When was treatment given? Date
Who provided the treatment?
Nature of treatment:
What happened after the initial treatment?
Mode of transport (if leaving site)
About the Accident/Incident
Area (if at customers property)
Weather/Environment
If OTHER, provide details
Give as much detail as you can about: weather or ground conditions, names of substances and equipment
What were the sequence of events leading up to this incident taking place?
What was the immediate cause of this incident?
What equipment was being used at the time of the incident?
What PPE was being used at the time?
What Happened
Add any relevant photos
If NO, please describe why not.
What was the Root Cause of this incident?
What time scale has been set to implement these actions?
...If YES, what are they and who have you contacted to arrange them?
I agree that the information contained on this form is correct as far as I am aware.
I understand that the company will use this information to meet its Health and Safety reporting and r
Managers Signature
Use this template