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Accident Report Form

An incident investigation form documents an incident that occurred on an unspecified date involving contractor activity. The incident is classified at a level 3 in terms of safety and health. The form collects details of the incident location, those involved, and risk rating. A description of findings from investigating the incident is provided. Required actions are listed along with who is responsible and deadlines. Significant learnings from the incident are also noted. The investigation was concluded on an unspecified date by the lead investigator.

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Pono Mmelaedi
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29 views

Accident Report Form

An incident investigation form documents an incident that occurred on an unspecified date involving contractor activity. The incident is classified at a level 3 in terms of safety and health. The form collects details of the incident location, those involved, and risk rating. A description of findings from investigating the incident is provided. Required actions are listed along with who is responsible and deadlines. Significant learnings from the incident are also noted. The investigation was concluded on an unspecified date by the lead investigator.

Uploaded by

Pono Mmelaedi
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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Department Document Name Issue Date: November 2022

HSE Incident Review Date: November 2022


Investigation Form

ACCIDENT INVESTIGATION FORM


INCIDENT DATA AND CLASSIFICATION
SAFETY HEALTH ENVIRONMENT Fire
Fatal Level 5 Catastrophic Repeat Incident
LTI Level 4 Major Nearhit
First Aid Level 3 Moderate Substandard Act
Damage Level 2 Minor Substandard
Condition
Level 1 Nearhit/Major
Nearhit/Minor
Incident Date: Time:
Location: Contractor
:
Activity:
Risk rating of recurrence(tick appropriate box)
FRCG 1- Light vehicles Likelihood/ Insignificant Minor Moderate Major Catastrophic
consequence
FRCG 2-Mobile Equipment Almost certain L M H H H
FRCG 3-Equipment Safeguarding Likely L M M H H
FRCG 4-Isolation Possible L L M M H
FRCG 5-Working at Heights Unlikely L L L M M
FRCG 6-Lifting Operations Rare L L L L L
INCIDENT DESCRIPTION (Include Picture where Possible)

FINDINGS
Department Document Name Issue Date: November 2022
HSE Incident Review Date: November 2022
Investigation Form

ACTIONS By Who By When

SIGNIFICANT LEARNINGS

Date Investigation Concluded: Lead Investigator:

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