Accident Investigation Form

Incident Follow-Up & Lessons Learned

Please complete this form once the investigation has been completed. The purpose of this form is to record lessons learned and ensure preventative actions are implemented.

Incident Details

Incident Reference Number Date of Incident Site / Department Incident Category Investigation Completed By Date Investigation Completed

Incident Summary

Brief description of what happened

Root Cause Analysis

Root cause(s) identified Contributing factors

Lessons Learned

What are the key lessons learned from this incident?

Corrective / Preventative Actions

Action 1 – What action is required? Responsible Person Target Completion Date Action 2 – What action is required? (optional) Responsible Person Target Completion Date

Communication of Lessons

Have lessons learned been communicated to staff? Method of communication Departments informed

Risk Assessment Review

Was the risk assessment reviewed following the incident? Were safe systems of work updated following the incident?

Incident Report Upload

Upload a copy of the accident / incident report

Additional Review Information

Any other relevant information from the reviewer

Manager Review

Manager comments Manager Name