Accident Investigation Report REF: Number Notification of Accident at work In the event of an Accident, please complete the following: Site: Date of Accident: Department: About the person involved in the accident: Name: Address: Male: Female: Date of birth: Occupation: Home Telephone Number: Length of Service: Operation: Site Name: Address: Time of Accident: (Please use 24 hr format) Shift Pattern: Location of accident: (if off site please include address) Warehouse Yard Delivery Point Office Pick up point Other (Please Specify) Job Description at time of accident: Store delivery/Collection Garment processing Pack/repack Other (Please Specify) FLT driving Unloading Loading Order Picking Environmental Conditions: Dark Light Poorly Lit Direct Sunlight Dry Wet Slippery Windy Noisy Quiet Other: Hot Warm Humid Cold S: Health Safety Accident Investigation AIR – AI-001.doc Version 1.4 (July 2008) Even Floor Uneven Different levels Foggy Page 1 of 12 Accident Investigation Report Accident Causation: Lifting Operation of equipment without authorisation/training Faulty equipment Slips Trips Falls Personal Attack Not wearing PPE Cutting corners Pulling Falls from height Falling stock/equipment Equipment failure Horseplay Impact injury Other (Please specify) Parts of the body Affected: Abdomen Ankle Left Right Arm Left Right Back Chest Elbow Eye Foot Face Finger(s) Groin Hand Head Knee Leg Neck Left Left Left Right Right Right Left H Right H Left Right Left Left Right Right Left H Left Left Right H Right Right Shoulder Thumb Thigh Wrist Removal of safety guards Pushing First Aid Was first aid administered Yes Name of first aider: Were first aid facilities adequate If not give reason why No Did you know the location of the first aider Yes No Did you know the location of the first aid box Yes No Was hospital treatment necessary Yes No Accident Book Did you know the location of the accident book Yes No Has all the information required been entered into the accident book Yes No H
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