AIIR3 – Accident/Incident Report Form

1. General information
Date of Accident	DD/MM/YYYY
Employee Name
Service
Team Name
Based at
Time of accident	24hr – 00:00
Location of accident
Investigating Manager
Investigation assisted by
Date of investigation	DD/MM/YYYY

2. Accident summary	Please tick
Injury Incident
Near miss
Member of the public incident/accident
Contact Incident/Accident
Verbal or Physical Abuse
Dangerous Occurrence

3. Accident type
Accident type	Please tick	Accident type	Please tick
Abusive/Threatening Behaviour		Fall from height
Being Exposed to fire or explosion		Hit by falling/moving/flying object
Being Trapped by something collapsing/overturning		Injured by animal
Bumping into something stationary		Aggravated previously sustained Injury (i.e. bad back made worse)
Carrying handling lifting		Multiple accident types
Contact with electricity or electrical discharge		Near Miss
Contact with harmful substance		Physical Assault
Contact with moving machinery/ equipment/ vehicle		Slips, Trips, Falls on the same level
Contact with Sharp Object (Blade)		Road Traffic Incident
Contact with Puncturing Object (Needle)		Vehicle Accident (Not involving another vehicle)
Drowned or Asphyxiated		Other -

4. Injury or Damage Location
Did an injury occur?	Y/N
If an injury has occurred, describe its location, size and appearance below.
Did any damage occur?	Y/N
If damage has occurred, describe its location, size and appearance below.
Insert or attach any relevant photos in the box below.

5. Type of injury (Tick all that apply)
Injury type	Please tick	Injury Type	Please tick
Amputation		Internal Injury
Bite		Natural Causes
Burns and Scalds		Near Miss
Choking (Asphyxia)		Phycological (Shock etc.)
Cuts		Physical Abuse
Disease (Lymes etc.)		Rash (i.e. dermatitis)
Dislocation		Sprains and Strains
Drowning or Near Drowning		Superficial injuries (bruising etc.)
Electrical Injury (burn, shock)		Needlestick Injury
Eye Injury		Verbal Abuse
Fracture		No Injury
Head Injury (Concussion, dental etc.)		Other -

6. Accident details

Name of injured person/ Damaged Equipment

Job title / Purpose

Age Group of person involved in accident – Or would it be better to use DOB

18-24

25-34

35-44

45-54

55-64

64-74

75 or older

If a vehicle the type of vehicle / mobile plant involved

Car

Van

Truck

Tractor

Telehandler

Forklift Truck

MEWP

Pickup

Trailer

Excavator

Mini Excavator

Road Sweeper Large

Road Sweeper Small

Refuse Lorry

Refuse Lorry large

Was the individual carrying out their usual duties?		Y / N	If No, include why in box below.
Please explain what happened – What occurred leading up to the event.
Persons involved in task that led to accident and their roles
Name	Job title			Role in event.
Resulting outcome – What the event resulted in, and actions taken following event.

Post-Accident relevant information.
At the time of the investigation where was the injured person / Equipment?
What was the first day of absence?	DD/MM/YYYY
Date returned to work (if known)	DD/MM/YYYY
Total days lost (current number with “+” if not yet resumed/returned)
If an injury was caused by manual handing and resulted in back pain, is there a history of back pain?	Yes / No – If yes what and what can be done to assist?
Is the employee/are the employees happy to continue with their normal job in the future?	Yes / No – If not, why?

7. Documentation
What task was being undertaken?
Had a site/task specific risk assessment been undertaken?	Yes / No – If no, why?
Had the employee seen and signed for this risk assessment?	Yes / No – If no, why?
Were all aspects of the risk suitably identified and controlled.	Yes / No – If no, why?
Was a safe system of work in place?	Yes / No – If no, why?
Did this safe system of work clearly lay out all steps in the task in a detailed manner?	Yes / No – If no, why?
Have these documents now been reviewed?	Yes / No – If no, why?
Do these documents need to be updated following the accident?	Yes / No – If ,why?
Who was supervising the task?

8. Training
Has training been provided for the use of the equipment/tools involved?	Yes / No – If no, why?
Is the person involved familiar with the equipment/tools involved?	Yes / No – If no, why?
What training have all people involved in the accident had for task that was being performed?
Is this training sufficient to enable the task to be carried out safely?	Yes / No – If no, why?
Is there additional training that would benefit the employee or team?	Yes / No – If yes, what?
Was the employee authorized to carry out the task?

9. Equipment
Was the correct equipment used to undertake the task?	Yes / No – If no, why?
Specify the equipment used in the task by those involved.
What safety equipment / aids were used?
Was the correct PPE worn?	Yes / No – If no, why?
Specify the PPE used?

10. Environment
Is the area enclosed or open to the elements?
Was the access to the area suitable?	Yes / No – If no, why?
What were the weather conditions at the time of the accident (visibility)?
What were the lighting conditions in the task's area?
Did the ground surface have any bearing on the accident?	Yes / No – If yes, how?

11. Other information
Did the emergency procedures work after the accident occurred?	Yes / No – If no, why?
Was any 1^st Aid required?	Yes / No
What 1^st Aid was provided?
Name of 1^st Aider (If 1^st Aid was provided)
Was hospital treatment required?	Yes / No
What hospital treatment was given?
Were there any witnesses? (Please insert any statements and CCTV screenshots where applicable.)
Has this type of accident happened before? If yes, give details
Was another person a contributing factor in this accident?	Yes / No – If yes, how?
Is there anything that the employee could have done to prevent this?	Yes / No – If yes, how?
Is there anything that management could have done to prevent this?	Yes / No – If yes, how?

12. Causes

The purpose of an investigation is to identify the root, underlying and immediate causes of the accident and the factual events that led up to it.

Immediate Causes:

Underlying Causes:

Root Causes:

13. SMART Actions
The following actions have been identified by the investigating manager.
Actions	Responsibility	Timescale

14. Supporting Document
Link all supporting documentation and evidence
Name of Supporting Document	Link

15. Corporate Health and Safety Team Comments

16. Sign Off
Investigating Officer Name	Signature	Date
Corporate Health and Safety Advisor	Signature	Date