Accident and Incident Report Form - ver.3.2 09/23

• 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?

  Yes

  No

• Please contact a member of the SHEQ team to make them aware of the accident now.

• Event Date and time

  Date

• Department

  Select Installations Manufacturing Head Office Sales External contractor Member of the public Training Academy

  • Installations
  • Manufacturing
  • Head Office
  • Sales
  • External contractor
  • Member of the public
  • Training Academy

• Depot

  Select Accrington Birmingham Bury St Edmunds Crawley Crayford Darlington Exeter Gloucester Milton Keynes Newbury Nottingham South Wales Warrington Wombwell

  • 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
  Address

• Please describe the location where the accident occurred ( For example, "rear of property, stone steps to garden")

• Department/Area

  Glass

  PVC

  PCW

  Yard

  Office

• Location of Event (cells)

  Select

• Building

  Style House

  Synergy House

  External Area

• Floor

  Select Ground 1st Floor 2nd Floor 3rd Floor 4th Floor Stores

  • Ground
  • 1st Floor
  • 2nd Floor
  • 3rd Floor
  • 4th Floor
  • Stores

• Floor

  Ground

  1st

  2nd

• Head Office Department

• Site

  Select 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

  • 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

  Select Customer Passer-by/unrelated to the business

  • Customer
  • Passer-by/unrelated to the business

Incident type

• Please select the type of incident that occurred

  Select Accident Medical incident Incident (accident without physical injury)

  • 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

  Drawing

• Please select the injury location on the IP

  Select 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

  • 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

  Select Left Right

  • Left
  • Right

• Please indicate which side

  Select Left Right

  • Left
  • Right

• Please indicate which side

  Select Left Right

  • Left
  • Right

• Please indicate which side

  Select Left Right

  • Left
  • Right

• Please indicate which side

  Select Left Right

  • Left
  • Right

• Please indicate which side

  Select Left Right

  • Left
  • Right

• Please indicate which side

  Select Left Right

  • Left
  • Right

• Please indicate which side

  Select Left Right

  • Left
  • Right

• Please specify which finger/thumb was injured

  Select Thumb Index finger Middle finger Ring finger Little finger

  • Thumb
  • Index finger
  • Middle finger
  • Ring finger
  • Little finger

• Please specify which finger/thumb was injured

  Select Thumb Index finger Middle finger Ring finger Little finger

  • Thumb
  • Index finger
  • Middle finger
  • Ring finger
  • Little finger

• Please indicate which side

  Select Left Right

  • Left
  • Right

• Please indicate which side

  Select Left Right

  • Left
  • Right

• Please indicate which side

  Select Left Right

  • Left
  • Right

• Please indicate which side

  Select Left Right

  • Left
  • Right

• Please indicate which side

  Select Left Right

  • Left
  • Right

• Please indicate which side

  Select Left Right

  • Left
  • Right

• Please indicate which toe(s)

  Select Big toe Index toe Middle toe 4th toe Little toe

  • Big toe
  • Index toe
  • Middle toe
  • 4th toe
  • Little toe

• Please indicate which toe(s)

  Select Big toe Index toe Middle toe 4th toe Little toe

  • 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

  Select 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

  • 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?

  Yes

  No

• Photos of the scene available?

  Yes

  No

PPE

• Was the required PPE worn correctly and in good condition? (where applicable)

  Yes

  No

  N/A

• 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)

  Select 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

  • 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)

  Select 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

  • 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)

  Yes

  No

• Name of person(s) directly involved in the incident (if applicable)

• Please describe the nature of the incident

Photos

• Photos available?

  Yes

  No

• Photos of the scene available?

  Yes

  No

• Please proceed onto Section 1: Event Details on the next page to complete your section.

• 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?

  Yes

  No

• Job title

• Do you have the IP's home address to hand?

  Yes

  No - but available from HR

  No - nothing on record

• Home address

• Are the next of kin details available?

  Yes

  No - but available from HR

  No - nothing on record

• 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.

  Sign

Training

• Please select the level of competence of the IP

  Select 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

  • 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?

  Yes

  No

• Please name the machinery or equipment involved

• Please state the location of the above

• Was the machine/equipment locked out immediately?

  Yes

  No

• Please give your reasons why

• Please give details of any chemicals involved (if any)

Additional Information

• Did the event occur on the job?

  Yes

  No

• Weather conditions

• Hours worked prior to the event (if applicable)

• Lighting

• Was lone work involved in the factors of the event?

  Yes

  No

• Please provide any additional information that may be relevant

First Aider Details

• First Aid given?

  Yes

  No

• 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.

  Sign
Statements - Witness

• Was there a witness present at the scene of the event?

  Yes

  No

• 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.

  Sign

• PL/Depot Managers/Line Managers Sign-off to confirm completion of their section

  Sign

• Severity

  Select 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

  • 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?

  Yes

  No

• 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

  Yes

  No

• Was the alleged process of the activity carried out by the IP at the time of the accident feasible?

  Yes

  No

• Please explain why

• Was the IP suitably trained for the activity?

  Yes

  No

• Please briefly explain why

• Have containment measures been implemented?

  Yes

  No

• Please describe what has been implemented

• Is this report complete?

  Yes

  No

• Please review with SHEQ lead and close-off accident via sign-off

• Please indicate what needs to be actioned further

  Root cause analysis required

  Further investigation required

  Other (please specify)

• undefined

Sign-off

• Add signature

  Sign