A1 RIDDOR Incident/Near Miss Report Template

• Incident location

• Prepared by

• Is the incident reportable to RIDDOR?

  Yes

  No

  N/A

• Specify the incident.

Section 1: Company and Incident Reporter Information

• Name of company/organisation

• Address of company/organisation
  Address

• Name of incident reporter

• Job title

• Contact number

• Email address

Section 2: Person(s) Affected

Person Affected

• Name

• Date of birth

  Date

• Home address

• Contact number

• Job title

• Position

  Employee

  External visitor

  Self-employed

  Member of the public

  Other

• Specify

Section 3: Incident Information

• Date of the incident

  Date

• Time of the incident

  Date

• Location of the incident

  Within the specified premises

  Elsewhere in the organisation

  At someone else's location

  In a public place

• Specify which department or area the incident took place.

• Specify the exact location.
  Address

• Kind of incident

  Select Contact with moving machinery or material being machined Hit by a moving, flying, or falling object Hit by a moving vehicle Hit something fixed or stationary Slipped, tripped, or fell on the same level Fell from a height Trapped by something collapsing Drowned or asphyxiated Exposed to, or in contact with, a harmful substance Exposed to fire Exposed to an explosion Contact with electricity or an electric discharge Injured by an animal Physically assaulted by a person Other type of incident

  • Contact with moving machinery or material being machined
  • Hit by a moving, flying, or falling object
  • Hit by a moving vehicle
  • Hit something fixed or stationary
  • Slipped, tripped, or fell on the same level
  • Fell from a height
  • Trapped by something collapsing
  • Drowned or asphyxiated
  • Exposed to, or in contact with, a harmful substance
  • Exposed to fire
  • Exposed to an explosion
  • Contact with electricity or an electric discharge
  • Injured by an animal
  • Physically assaulted by a person
  • Other type of incident

• How high was the fall (in metres)?

• Specify the type of incident.

• Are there any witnesses?

  Yes

  No

  N/A
Witness

• Name

• Contact information

Section 4: Incident Description

• Describe in detail what happened, why the incident occurred, and other helpful information. You can also capture photos or videos of the incident to give proper context.

• Incident description

Section 5: Details about the Injury

• Description of the injury (what it is, which body parts are affected, etc.)

• Photo of the injury

  Media

• Severity of the injury

  Select Fatal Major Injury to an employee or self-employed person which prevented them from doing their normal work for more than 3 days Injury to a member or the public which meant they had to be taken from the scene

  • Fatal
  • Major
  • Injury to an employee or self-employed person which prevented them from doing their normal work for more than 3 days
  • Injury to a member or the public which meant they had to be taken from the scene

• Was any first aid administered on the site?

  Yes

  No

  N/A

• What treatment was provided?

• Who administered the treatment?

• Was the victim taken to the hospital immediately?

  Yes

  No

  N/A

• Which hospital were they brought to?

• What treatment was provided?

• How long did they stay in the hospital?

• Recommendations

• Name and signature of incident reporter

  Sign

• Job title