666666 Accident Report Form - Version 001 - NOV 2020

• Project / PC / Job?

  Select

• Template Title

  Accident

• Date and time of incident

  Date

• Has there been an injury sustained?

  YES

  NO

• Prepared by

• Location
  Address

Injured Person Background

• Name of Injured Person?

• Gender (Binary)

  Male

  Female

• Date of Birth?

• Start date?

  Date

• Occupation

  Select

• Give details

• Is the injured person? Choose from list?

  Employee

  Contractor

  Sub-contractor

  Agency

  Member of the public

• Employer (If sub-contract)

• Telephone Number

• Address

• Town/City

• Post code

Notifications / Reportable Accidents

• The following is was it deemed as Reportable under RIDDOR 2013.
  
  -- fractures, other than to fingers, thumbs and toes
  amputations
  -- any injury likely to lead to permanent loss of sight or reduction in sight
  -- any crush injury to the head or torso causing damage to the brain or internal
  organs
  -- serious burns (including scalding) which:covers more than 10% of the body
  causes significant damage to the eyes, respiratory system or other vital organs
  -- any scalping requiring hospital treatment
  -- any loss of consciousness caused by head injury or asphyxia
  -- any other injury arising from working in an enclosed space which:
  leads to hypothermia or heat-induced illness requires resuscitation or
  admittance to hospital for more than 24 hours
  
  Over-seven-day incapacitation of a worker
  --Accidents must be reported where they result in an employee or self-employed person being away from work, or unable to perform their normal work duties, for more than seven consecutive days as the result of their injury. This seven day period does not include the day of the accident, but does include weekends and rest days. The report must be made within 15 days of the accident.
  
  Non fatal accidents to non-workers (eg members of the public)
  
  Accidents to members of the public or others who are not at work must be reported if they result in an injury and the person is taken directly from the scene of the accident to hospital for treatment to that injury.

• Do the HSE need to be notified? (Reportable under RIDDOR)

  Yes - Notifiable (RIDDOR)

  No

• Online form to be completed by Responsible Person (Director or nominated Safety Advisor)

Injury Details

• Describe fully how the accident happened? Give as much detail as possible.

• Take photos of the surrounding environment the employee was in prior to the event

  Media

• Accident type

  Select

• Date and time of event

  Date
• Exact location of event
  Address

• What part of the body was injured?

  Select Head Hand Arm Chest Shoulder Back Foot Upper leg Lower leg Knee Back Stomach

  • Head
  • Hand
  • Arm
  • Chest
  • Shoulder
  • Back
  • Foot
  • Upper leg
  • Lower leg
  • Knee
  • Back
  • Stomach

• Mark where the injury is on the body

  Drawing

• Injury type?

  Select Slip, trip, fall Muscle strain Falling object Struck by Struck against Caught in or on machinery Contact with energy Contact with substance Over exertion Substance release Electrical OTHER

  • Slip, trip, fall
  • Muscle strain
  • Falling object
  • Struck by
  • Struck against
  • Caught in or on machinery
  • Contact with energy
  • Contact with substance
  • Over exertion
  • Substance release
  • Electrical
  • OTHER

• Please describe.

  Yes

  No

  N/A

• What was the injured person doing prior to the event?

• Was equipment, tools being used?

  Yes

  No

• Explain what equipment, tools were being used?

• Was the equipment defective or faulty?

  Compliant

  Non-Compliant

  N/A

• Give details

• Add any images as necessary

  Media

Witness Statements

• Were there any witnesses?

  Yes

  No

• Add witness

Witness

• Enter witness name

• Contact number

• Witness statement (What was seen)

• Witness signature

  Sign

First Aid / Emergency Services

• Was first aid given? Injured person went to doctor/ hospital?

  Yes

  No

• Was an entry made in the site Accident Book?

  Yes

  No

  N/A

• Show image of this

  Media

• Please explain why and ensure this is corrected.

• Did the person go to hospital

  Yes

  No

  N/A

• Give name / address of hospital

  Yes

  No

  N/A

• Police were called to the scene

  Yes

  No

• Police reference number and any other details?

Conclusion and action taken to prevent recurrence

• Were safe systems of work, procedures and safety regulations in place and used?<br><br>These are Risk Assements and Methods Statements for contractors or SWPs for employees

  Yes

  No

  N/A

• Give details of breach

• Did the IP accept these systems?

  Yes

  No

  N/A

• Was there proof of training, inductions and briefings etc?

  Yes

  No

  N/A

• Show proof that this was agreed

  Media

• Which of the following was communicated?

Improvements and proof
Repeat this as necessary for the choices and lists provided.

• List of proof. What improvements are required to prevent recurrence

  Select Risk Assessment and Method statement COSHH information and assessments Has the IP received relevant short duration training? As a Site Safety Inspection been carried out in the last 7 days? Are there any other training certificates Relevant ToolboxTalks

  • Risk Assessment and Method statement
  • COSHH information and assessments
  • Has the IP received relevant short duration training?
  • As a Site Safety Inspection been carried out in the last 7 days?
  • Are there any other training certificates
  • Relevant ToolboxTalks

• Show proof of Risk Assessment

  Media

• What action/improvement is required?

• Do any improvements need to be communicated?

  Yes

  No

  N/A

• By what methods?

  Select TBTs RAMS (Update) Training Improvements / changes by others (PC / other contractors)

  • TBTs
  • RAMS (Update)
  • Training
  • Improvements / changes by others (PC / other contractors)

• Give details.

• Show proof of COSHH Assessment

  Media

• What action/improvement is required?

• Do any improvements need to be communicated?

  Yes

  No

  N/A

• By what methods?

  Select TBTs RAMS (Update) Training Improvements / changes by others (PC / other contractors)

  • TBTs
  • RAMS (Update)
  • Training
  • Improvements / changes by others (PC / other contractors)

• Give details.

• Show proof of Training

  Media

• What action/improvement is required?

• Do any improvements need to be communicated?

  Yes

  No

  N/A

• By what methods?

  Select TBTs RAMS (Update) Training Improvements / changes by others (PC / other contractors)

  • TBTs
  • RAMS (Update)
  • Training
  • Improvements / changes by others (PC / other contractors)

• Give details.

• Show proof of Site Audit done in last 7 days

  Media

• Was the audit completed in last 7 days.<br>This can include weekly audit or PUWER Audit.

  Yes

  No

  N/A

• Give details why not?

• What action/improvement is required?

• Do any improvements need to be communicated?

  Yes

  No

  N/A

• By what methods?

  Select TBTs RAMS (Update) Training Improvements / changes by others (PC / other contractors)

  • TBTs
  • RAMS (Update)
  • Training
  • Improvements / changes by others (PC / other contractors)

• Give details.

• Has a relevant TBT been completed?

  Yes

  No

  N/A

• Why not?

  Yes

  No

  N/A

• What action/improvement is required?

• Proof -Image or Pdf

  Media

• Do any improvements need to be communicated?

  Yes

  No

  N/A

• By what methods?

  Select TBTs RAMS (Update) Training Improvements / changes by others (PC / other contractors)

  • TBTs
  • RAMS (Update)
  • Training
  • Improvements / changes by others (PC / other contractors)

• Give details.

Sign off

• Has the Injured Person been made aware of the findings of ANY Investigation?

  Yes

  No

  N/A

• Give details or add images and Pdfs

• Please ensure that when the company who employed you to undertake the work contact you that this is recorded here....

• Injured persons name

• Injured person signature

  Sign

• Supervisors name at time of the incident

• Supervisors signature (where possible)

  Sign

• Has the IP been contacted with regards to this incident?

  Yes

  No

  N/A

• Give details

• Who contacted you?

• When?

  Date

• What was the nature of their enquiry? Give as much info as possible?

• Have you been given information relating to the incident?

  Yes

  No

  N/A

• What information did you give?

  Yes

  No

  N/A

• When did you give it?

  Date

• Who did you give it to?

• What was their role?

• Have you been asked to sign anything relating to accepting procedures after the event?

  Yes

  No

  N/A

• Give details

• Has the IP (Injured Person) been away from normal duties for more than 7 days including weekends?

  Yes

  No

  N/A

• This is normally reportable to the HSE.

• From your knowledge has the company indicated that they have reported this to the HSE?

  Yes

  No

  N/A

• What information have you given relating to this report?

• Please keep all the relevant information as required. Remember it is not your responsibility to report the incident but the employing companies and this includes -sub-contract works.

Have you suffered with any other issues physically or mentally after the inident?

--Note you can repeat and add this sectionas many times as you need.

• What did you suffer with?

  Physical

  Mental

  Other

• Give details

• From date

  Date

• To date

  Date

• Have you recieved any medical advice or assistance

  Yes

  No

  N/A

• Give details

Finally...
Use this section to add any other information as required.
--Note you can repeat and add this sectionas many times as you need.

• Date and time

  Date

• Relevant Information Record as much as possible