Information gathered about the Incident

Injured Person Background

Name of Injured Person?

Gender (Binary)

Date of Birth?

Start date?
Occupation

Give details

Is the injured person? Choose from list?

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)

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
Accident type
Date and time of event
Exact location of event
What part of the body was injured?
Mark where the injury is on the body
Injury type?

Please describe.

What was the injured person doing prior to the event?

Was equipment, tools being used?

Explain what equipment, tools were being used?

Was the equipment defective or faulty?

Give details

Add any images as necessary
Witness Statements

Were there any witnesses?

Add witness

Witness

Enter witness name

Contact number

Witness statement (What was seen)

Witness signature
First Aid / Emergency Services

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

Was an entry made in the site Accident Book?

Show image of this

Please explain why and ensure this is corrected.

Did the person go to hospital

Give name / address of hospital

Police were called to the scene

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?

These are Risk Assements and Methods Statements for contractors or SWPs for employees

Give details of breach

Did the IP accept these systems?

Was there proof of training, inductions and briefings etc?

Show proof that this was agreed

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
Show proof of Risk Assessment

What action/improvement is required?

Do any improvements need to be communicated?

By what methods?

Give details.

Show proof of COSHH Assessment

What action/improvement is required?

Do any improvements need to be communicated?

By what methods?

Give details.

Show proof of Training

What action/improvement is required?

Do any improvements need to be communicated?

By what methods?

Give details.

Show proof of Site Audit done in last 7 days

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

Give details why not?

What action/improvement is required?

Do any improvements need to be communicated?

By what methods?

Give details.

Has a relevant TBT been completed?

Why not?

What action/improvement is required?

Proof -Image or Pdf

Do any improvements need to be communicated?

By what methods?

Give details.

Sign off

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

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

Supervisors name at time of the incident

Supervisors signature (where possible)

Has the IP been contacted with regards to this incident?

Give details

Who contacted you?

When?

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

Have you been given information relating to the incident?

What information did you give?

When did you give it?

Who did you give it to?

What was their role?

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

Give details

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

This is normally reportable to the HSE.

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

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?

Give details

From date
To date

Have you recieved any medical advice or assistance

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

Relevant Information Record as much as possible

Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.