Incident Investigation Form
REF-HSEMNGTS/ATT00/BGT-2024/Rev00
Base Drainage (Water Run-off/Retention) Upgrades
Contract No:
INCIDENT INVESTIGATION FORM
Revision History
SL.No. Description Revision number Revision date Approved by
Incident investigation
1 00 22 April 2024
Form
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BUILD, GROW, THRIEVE
INCIDENT INVESTIGATION FORM
1 INCIDENT INVESTIGATION FORM
INCIDENT INVESTIGATION FORM
Site: Report Distribution (the day after incident):
Project Managers
Area.: HSE Manager
V2X
Location:
INJURED PERSON
1. Name
2. Nationality
3. Address
4. Employer
5. Male / Female 6. Date of Birth
INCIDENT
7. Date & Time of incident Date: Time:
8. Exact location (Building/Location/Area)
9. What time did the injured person start work
on the day of incident?
10. When did they stop work as a result of the
incident?
11. What was the injured person doing at the
time of the incident?
12. At what location was the injured person working?
Excavation Basement Ground Roof Upper Level Other: ____________
12a. If other, describe:
13. Was this the injured person authorized to work? Yes No
13a. If authorized, how?
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BUILD, GROW, THRIEVE
INCIDENT INVESTIGATION FORM
14. Nature and extent of injury:
(State exact parts of body injured / draw
diagram)
15. If injured person fell, or object fell on them,
state height of the fall:
16. Was first-aid given to the injured person on site?
17. If yes, by whom and are they certified as a first
aider?
18. To whom on site was the incident first reported?
19. What were the causes of the incident?
(attach drawings/sketches if necessary)
20. Was scaffold involved? Yes No
21. Was machinery involved? Yes No
22. If yes, supply name of machine and details of
the part causing injury.
GENERAL
23. Was the injured person taken to hospital? Yes No
24. If yes, state name and address of hospital:
25. How long is the injured person likely to be off
work?
26. Were there any witnesses to the incident? Yes No
27. Was the injured person working under Yes No
supervision at the time of the incident?
28. If yes, give Supervisor’s name.
29. Was the task/activity covered by a risk Yes No
assessment?
30. Was a method statement prepared for the Yes No
task/activity?
31. Was the method statement being followed? Yes No
32. Was a work permit or hot work permit issued? Yes No
33. Serial numbers of any permits issued. PTW
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BUILD, GROW, THRIEVE
INCIDENT INVESTIGATION FORM
34. Were the emergency services involved? Yes No
35. Is the incident reportable to the authorities under Yes No
local / national regulations?
36. If it is reportable, to who, how and when was it
reported?
37. If reported, is an external investigation being
undertaken?
38. Recommendations / Comments to prevent recurrence
Name: __________________________ Signature: _____________________________
Designation: _______________________ Time & Date: __________________________
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BUILD, GROW, THRIEVE
