Title Page
-
Please refer to the Reporting Flowchart for the steps in reporting an accident
FOR PRODUCTION LEADER/DEPOT MANAGER/LINE MANAGER- to be completed within 1 hour of incident
-
Please notify a member of SHEQ immediately
-
Has this been complete?
-
Please contact a member of the SHEQ team to make them aware of the accident now.
-
Event Date and time
-
Department
- Installations
- Manufacturing
- Head Office
- Sales
- External contractor
- Member of the public
- Training Academy
-
Depot
- Accrington
- Birmingham
- Bury St Edmunds
- Crawley
- Crayford
- Darlington
- Exeter
- Gloucester
- Milton Keynes
- Newbury
- Nottingham
- South Wales
- Warrington
- Wombwell
-
Contract number (if accident occurred on site)
-
Location of the accident
-
Please describe the location where the accident occurred ( For example, "rear of property, stone steps to garden")
-
Department/Area
-
Location of Event (cells)
-
Building
-
Floor
- Ground
- 1st Floor
- 2nd Floor
- 3rd Floor
- 4th Floor
- Stores
-
Floor
-
Head Office Department
-
Site
- Birmingham/Edgbaston
- Blackburn
- Brighton at Crawley
- Briston/Avon Sales
- Chester
- Coventry
- Doncaster
- Exeter
- Guildford
- Hull
- Leeds
- Liverpool
- Manchester
- Middlesborough
- Nottingham
- Norwich
- Peterborough
- Plymouth
- Preston
- Reading
- Romford
- Salford (Glossop in Stockport)
- Sheffield/Rotherham
- Sittingbourne
- Southampton
- Stoke
- Swansea
- Swindon
- Truro
- Watford - Hemel Hempstead
- Wolverhampton
-
Name of company (if applicable)
-
Relation to the business
-
Relation to the business
- Customer
- Passer-by/unrelated to the business
Incident type
-
Please select the type of incident that occurred
- Accident
- Medical incident
- Incident (accident without physical injury)
Injury Details
-
Name of casualty
-
Please indicate the location and the nature of the injury on the diagram
-
Please select the injury location on the IP
- Head
- Eye(s)
- Ear(s)
- Nose
- Mouth
- Face
- Neck
- Shoulder(s)
- Upper arm(s)
- Lower arm(s)
- Wrist(s)
- Hand(s)
- Finger(s) or thumb(s)
- Chest
- Torso
- Back
- Groin
- Buttocks
- Hip
- Upper leg(s)
- Lower leg(s)
- Knee(s)
- Ankle(s)
- Foot/feet
- Toe(s)
- Other
-
Please indicate which side
- Left
- Right
-
Please indicate which side
- Left
- Right
-
Please indicate which side
- Left
- Right
-
Please indicate which side
- Left
- Right
-
Please indicate which side
- Left
- Right
-
Please indicate which side
- Left
- Right
-
Please indicate which side
- Left
- Right
-
Please indicate which side
- Left
- Right
-
Please specify which finger/thumb was injured
- Thumb
- Index finger
- Middle finger
- Ring finger
- Little finger
-
Please specify which finger/thumb was injured
- Thumb
- Index finger
- Middle finger
- Ring finger
- Little finger
-
Please indicate which side
- Left
- Right
-
Please indicate which side
- Left
- Right
-
Please indicate which side
- Left
- Right
-
Please indicate which side
- Left
- Right
-
Please indicate which side
- Left
- Right
-
Please indicate which side
- Left
- Right
-
Please indicate which toe(s)
- Big toe
- Index toe
- Middle toe
- 4th toe
- Little toe
-
Please indicate which toe(s)
- Big toe
- Index toe
- Middle toe
- 4th toe
- Little toe
-
Please specify
-
Please describe the nature of the injury (e.g. cut, bruise etc.)
-
Accident type
- Slip, trip, or fall at same level
- Fall from height
- Motor vehicle collision
- Hit by falling object
- Hit by moving/flying or ejected object
- Contact with moving machinery
- Strike against stationary object
- Manual handling
- Entrapment
- Tool use
- Trapped body part/ crush accident
- Burn/scald
- Contact with substance
- Animal bite
-
Please give details of the task being performed at the time of the injury
Photos
-
Injury photos available?
-
Photos of the scene available?
PPE
-
Was the required PPE worn correctly and in good condition? (where applicable)
-
PLEASE RETAIN ALL PPE USED AT THE TIME OF THE ACCIDENT
-
Please list the PPE that was worn (PPE is to be retained by the PL/depot manager/line manager)
- Head Protection
- Eye Protection
- Gloves
- Wrist Protection (cuffs)
- Hearing Protection
- Safety Footwear
- Hi-visibility Clothing
- Covid PPE (face covering or visor indoors)
- RPE
- None
- Not Applicable
-
PLEASE RETAIN ALL PPE USED AT THE TIME OF THE ACCIDENT
-
Please list the PPE worn (PPE is to be retained by the PL/depot manager/line manager)
- Head Protection
- Eye Protection
- Gloves
- Wrist Protection (cuffs)
- Hearing Protection
- Safety Footwear
- Hi-visibility Clothing
- Covid PPE (face covering or visor indoors)
- RPE
- None
- Not Applicable
-
Name of casualty
-
Please describe the medical incident (fainting, heart attack, seizure etc.)
-
Does the person have a known underlying medical condition? (at the time of reporting)
-
Name of person(s) directly involved in the incident (if applicable)
-
Please describe the nature of the incident
Photos
-
Photos available?
-
Photos of the scene available?
-
Please proceed onto Section 1: Event Details on the next page to complete your section.
Section 1: Event Details - TO BE COMPLETED BY PL/Depot Managers/Line Managers within 24 hours
-
Using information available at the time of completing this form, describe the sequence of events, in a timeline format
Details of Injured Person (or Involved Persons for incidents)
-
Full name
-
Contact number
-
Is the person a worker for Safestyle?
-
Job title
-
Do you have the IP's home address to hand?
-
Home address
-
Are the next of kin details available?
-
Next of kin name
-
Next of kin contact details
-
Home address
-
Next of kin name
-
Next of kin contact details
Statements - IP
-
Please provide an initial IP statement
-
By signing this document I confirm that the statement is true and accurate.
-
Please provide a signature by the IP to confirm the above.
Training
-
Please select the level of competence of the IP
- Level 1: training pack completed
- Level 2: Training started with full supervision
- Level 3: Training started with minimum supervision
- Level 4: Fully trained and competent unsupervised
- Level 5: Trainer
-
Please save all training records into the accident folder
Machinery/Equipment Involved
-
Is any machinery or equipment directly involved in the incident?
-
Please name the machinery or equipment involved
-
Please state the location of the above
-
Was the machine/equipment locked out immediately?
-
Please give your reasons why
-
Please give details of any chemicals involved (if any)
Additional Information
-
Did the event occur on the job?
-
Weather conditions
-
Hours worked prior to the event (if applicable)
-
Lighting
-
Was lone work involved in the factors of the event?
-
Please provide any additional information that may be relevant
First Aider Details
-
First Aid given?
-
Full name of First Aider
-
Job title
-
Contact number
Statements - First Aider
-
Please provide a statement from the First Aider
-
By signing this document I confirm that the statement is true and accurate.
-
Please provide a signature by the First Aider to confirm the above.
Statements - Witness
-
Was there a witness present at the scene of the event?
-
Name of witness
-
Job role/relation to IP
-
Please provide a statement from the Witness
-
By signing this document I confirm that the statement is true and accurate.
-
Please provide a signature by the Witness to confirm the above.
-
PL/Depot Managers/Line Managers Sign-off to confirm completion of their section
FOR SHEQ USE ONLY
-
Severity
- Minor accident
- Lost time under 3 days
- Lost time over 3 days
- RIDDOR - lost time over 7 days
- RIDDOR - accident type (fractures excluding fingers and toes etc.)
- Incident
-
Please state the number of lost days
-
Please state the number of lost days
-
Please state the number of lost days
-
Is an investigation required?
-
Investigation Lead name
-
Interview with IP
-
Interview with witness(s)
-
Has the process of the activity been reviewed (e.g. via a demonstration) with the IP
-
Was the alleged process of the activity carried out by the IP at the time of the accident feasible?
-
Please explain why
-
Was the IP suitably trained for the activity?
-
Please briefly explain why
-
Have containment measures been implemented?
-
Please describe what has been implemented
-
Is this report complete?
-
Please review with SHEQ lead and close-off accident via sign-off
-
Please indicate what needs to be actioned further
-
undefined
Sign-off
-
Add signature