Accident/Incident Book

Report Details

Report Number:

Date of Entry:

Time of Entry:

Recorded by:

Affected Person Details

Full Name:

Job Title/Role:

Department:

Contact Number:

Email:

Status:

Incident Details

Date of Incident:

Time of Incident:

Location of Incident:

Type of Incident:

Accident Near Miss Dangerous Occurrence Work-related Illness Property Damage Security Breach Environmental Incident Other (specify):

Description of Incident

What happened? (Provide a clear and concise description of the incident):

Task being performed at time of incident:

Any equipment/substances involved:

Weather conditions (if relevant):

Injury Details (if applicable)

Was an injury sustained?

Type of injury:

Part(s) of body affected:

Severity of injury:

Minor (first aid only) Moderate (medical treatment required) Major (hospitalization required) Fatal

Treatment provided:

First Aid Provided by:

Name of Hospital (if applicable):

Witnesses

Were there any witnesses?

Name	Position/Role	Contact Details

Immediate Actions Taken

Immediate action taken following the incident:

By whom:

Date:

Time:

Cause Analysis

Direct causes (what directly led to the incident):

Root causes (underlying factors that contributed to the incident):

Environmental factors:

RIDDOR Reporting

Is this incident reportable under RIDDOR?

If Yes, date reported:

Report reference number:

Reported by:

Follow-up Actions

Corrective actions required to prevent recurrence:

Action Required	Person Responsible	Target Completion Date	Actual Completion Date	Status

Investigation

Further investigation required?

Investigation assigned to:

Investigation completion date:

Management Review

Reviewed by:

Position:

Date:

Comments:

Signatures

Person completing this form:

Date:

Manager/Supervisor:

Date:

Health & Safety Representative (if applicable):

Date:

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