AIIR4 – Corporate Health and Safety Accident/Incident Investigation Report
(Name of Accident/Incident)
1.0. Event Overview
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Persons Involved |
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Relationship to incident |
Name |
Address |
Contact Number |
Email Address |
Employee |
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Yes |
No |
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Injuries Sustained |
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Injured Person |
Part of the Body |
Brief description of injury |
Medical attention received? |
If yes, where? |
RIDDOR Reportable? |
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Equipment/Vehicles Involved |
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Type |
Registration/Identification |
Make |
Model |
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Incident/Accident Detail |
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Date |
Time |
Exact Location |
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2.0. Summary of Event
(provide a general overview of the incident, including the injuries and treatment received)
3.0. Scope of Investigation
(what will be looked at as part of this investigation)
4.0. Investigation Findings
(include your full investigation and findings)
5.0. Investigation Analysis
Immediate Causes:
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Underlying Causes:
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Root Causes:
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6.0. SMART Actions and Recommendations
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Action |
Responsible Officer |
Target Date |
Requirement |
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(requirement)
(action that could be considered)
(idealistic Action) |
7.0. Supporting Evidence
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Evidence |
Link/Attached |
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8.0. Sign Off
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Investigator |
(name) |
(signed) |
(Job Title) |
(date) |
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Reviewed By |
(name) |
(signed) |
(job Title) |
(date) |