Page 17 - Construction Forms
P. 17
TM
Event Investigation Form
If you have an accident Call HazardCo ASAP on 0800 555 339
Information Collection - Analysis
Work through the questions (What, When, Where, Why, Who, How etc) to find out what circumstances led
to the accident/incident. Be as detailed as you can.
Company Name:
What Happened? (brief summary of events)
When did it happen? (date & time)
Where did it happen? (location, description of worksite & surroundings & related equipment)
Who did it happen to? (employee, contractor, apprentice, experienced or inexperienced worker, trained,
untrained)
Why or How did it happen? (contributing factors; eg. fatigue, rushing, weather, equipment failure,
inattention, outsiders)
Remedial Action: (what are you going to do to prevent a similar event happening in the future - enter the
date you expect to complete this & who is responsible for doing it)
Actions Assigned Actions Complete:
to: Date / /
Investigation completed: Investigation Completed
Date: / / By:
Fax this completed form to HazardCo on 09 5236749 or email to info@hazardco.com
