Form 1 6 Accident Investigation Form by EORmoJ

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									Form 1.6 – Accident Investigation Form
Type of Incident :                                                                  Investigation :

                                            Yes   No      Details:
   Injury              Property/Equipment
                       Damage               Further Action Required

   Near Miss           Other………………            Report to Health & Safety Authority

Details of Incident


Date of Incident                                              Time of Incident                 am     pm
Witness Name                                                  Witness Contact
                                                              Details
Nature of Incident



Location of Incident
Description of
Incident


Details of Damage to
Equipment/Property?
Details of Injured Person(s) (if applicable)
Name

Address

Date of Birth

Occupation                                     Employer



Recommended Preventive Action
Details




Report Completed By:
Name                                               Position
Signature                                          Date


Record of Additional Information

Witness Statements                                 Pictures

CCTV/Video                                         Sketches/Drawing

								
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