Form 5.0 – Internal Accident/Incident Investigation Form
Internal Accident / Incident Investigation Form	
Part A – Details of Injured Person	
Name		Phone
		
Address

	Email		
	PPS Number		
	Date of Birth		
	Age		
	Position		
Safe Pass Number & Expiry Date		CSCS Details
		
Employment Type	Full Time	Part Time	Other
	
Occupation	Employee	COntractor	Member of the Public	Other	
Outcome
	Injury	Near Miss	Fatality	Other	
Part B – Details of Injury & Treatment	
Type of Injury (e.g. Burn, Cut, Sprain)		
Cause of Injury (e.g. fall, machine)		
Part of Body Injured 		
Agent (e.g. poor light)		
First Aid	Yes	No	First Aider		
Treated by Doctor?	Doctor’s Name		Address		
Hospitalised?	Hospital Name		Address
		
Treatment Received?
	
Part C – Details of Accident or Incident	
Date
		Time		
Location
	
Description of Accident / Incident

	
Other Information Available?	Witness	CCTV	Photo/Video	Other
e.g. physical evidence	
Part D – Witness Details (Who witnessed the accident/incident?)	
Name		Phone
		
Address

	Email
		
	PPS Number
		
	Date of Birth
		
	Age
		
	Position
		
Safe Pass Number & Expiry Date		CSCS Details		
Witness Statement Taken?	Yes	No	
Part e – Key Findings of Investigation	

1._________________________________________________________________________________

2.________________________________________________________________________________ 

3._________________________________________________________________________________

Part f – Actions to Prevent Reoccurrence	
Action	By Whom	Date	

			
Part g – Items Attached	
Sketches	Certification of Plant, Etc.	Photographs/Video	Risk Assessments	Training Records	
Yes               No
	Yes               No
	Yes               No
	Yes               No
	Yes               No
	
Detail Other Items / Useful Information

	
Part H – Other Information	
Accident Investigated By	
	Position		
Phone	
	Email		
Signed	
	Date