Title Page
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Conducted on
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Prepared by
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Location
Form
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This form is to be completed by the Line Manager, Designated Managers or SHEQ only NOT the employee
DETAILS
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Date & Time of Accident/Incident:
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Client:
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Location of Incident:
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One Serve/Job Number:
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MD Group Regional Office Location:
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Name and Contact Details of Operations Manager:
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Name, Job title and Contact Details of person completing form:
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Was the person completing this form witness to the incident?
DETAILS OF INJURED PERSON
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Injured Person
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Gender
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DOB:
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Full Name of Injured Person
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Job Title & Trade
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Contact Details:
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Name of Line Manager (if employee):
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Contact Details:
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Name of Company (if contractor)
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Contact Details
Incident Details
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INCIDENT TYPE: (tick one box only)
- Slip/Trip/Fall Same Level
- Struck by Moving Vehicle
- Fall From Height (1)
- Lifting/Handling
- Physical Assault
- Contact with Machinery/Tools
- Exposure to Harmful Substance (2)
- Drowning or Asphyxiation
- Trapped by Collapsing Object
- Contact with Electricity
- Injury by Animal
- Road Traffic Incident
- Repetitive Work
- Roof Work
- Exposed to Fire
- Exposed to Explosion
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(1) Distance of Fall
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(2) Details of Substance
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Other (Please Specify)
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CONTRIBUTORY CAUSE: (tick all relevant boxes)
- Operational Methods
- 3rd Party Activity
- Poor State of Equipment/Tools
- Physical Disability
- Poor Communication
- Protective Equipment Not Used
- Supervision
- Training
- Unavailability of Equipment
- Weather Conditions
- Absence of Adequate Rules
- Breaches of Rules or Instructions
- Contractor Activity
- Design of Equipment
- Excessive Driving Hours
- Heat/Light/Ventilation
- Housekeeping
- Inappropriate Use of Equipment
- Maintenance
- Mechanical/Material Failure
- No Roof Guarding
- Noise/Vibration
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Other: (Please Specify)
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INJURY
- Amputation
- Asphyxia
- Bruising
- Burn/Scald
- Concussion
- Crushing
- Dental
- Dermatitis
- Dislocation
- Eye Damage
- Fracture (Open/Closed)
- Gastrointestinal
- Hearing Damage
- Internal Injury(s)
- Laceration/Open Wound
- Poisoning
- Scratch/Graze/Cut
- Shock/Stress
- Sprain/Strain
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Other: (Please Specify)
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AREA INJURED
- Ankle
- Arm
- Back
- Chest
- Ear
- Eye
- Face
- Finger
- Foot
- Hand
- Head
- Hip
- Knee
- Leg
- Neck
- Shoulder
- Thigh
- Thumb
- Toe
- Wrist
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Injury Classification
First Aid
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Who administered first Aid?
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Registered First Aider
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Company
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Contact Details
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Treatment Given
Hospital Treatment
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Name of Hospital
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Telephone Number
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Treatment Given
Treatment by Doctor
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Name of Doctor
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Address
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Telephone Number
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Treatment Given
Witness Statements
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Were they any witnesses to the incident?
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Witness 1 Name
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Occupation
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Company
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Address
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Telephone No
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Statement Given
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Witness Statement should be attached to the completed form
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Witness 2 Name
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Occupation
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Company
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Address
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Telephone No
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Statement Given
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Witness Statement should be attached to the completed form
Incident Description
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Accident/Incident Description
Absence Details
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Start Date
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End Date
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Total Number of Days Absent
Cost
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Was the employee paid during their absence?
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Was any financial loss incurred on the project as a result of this absence, if so, please indicate approximate cost: £
INVESTIGATION (All accidents should be investigated by the Line Manager and this section completed)
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Name of investigator
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Job Title:
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Investigation Start Date
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Investigation End Date
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Contributory Factors: (brief description of factor leading to incident i.e. Unsafe Act = Disregarded safety instructions)
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Unsafe Act
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Unsafe Condition
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How could accident have been prevented?
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Main hazards or causes?
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What action are you taking to prevent recurrence?
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Line Manager Signature
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Date:
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Employee Signature
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Date
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Once completed, return this form SHEQ@MDGROUP.CO.UK
For H&S Use Only
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Cause of Accident:
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Recommended Follow Up Action:
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Urgency of follow up:
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Feedback to be circulated to:
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Entered onto Accident Database:
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Date Entered onto Accident Database:
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Reported to HSE under RIDDOR?
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Date Reported to HSE under RIDDOR?
