FORM 3.1 – 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

	
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 AND 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	

PART D – WITNESS DETAILS (WHO WITNESSED THE ACCIDENT/INCIDENT?)	
NAME		PHONE
		
ADDRESS

	EMAIL

PPS NUMBER

DATE OF BIRTH

AGE

POSITION

	
SAFE PASS NUMBER AND EXPIRY DATE		CSCS DETAILS		
WITNESS STATEMENT TAKEN?	YES	NO	
PART E – KEY FINDINGS OF INVESTIGATION	
LIST 

	
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