Accident / Incident / Near Miss Report

• Document No.

• Accident / Incident/ Near Miss Report

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

• Site Manager

Section 1 - Personal Details - Report Author

• Select date

  Date

• Report completed by

• Position

Section 1 - Personal Details - Involved/Injured Party Information

• Member of Public

  Yes

  No

  N/A

• Name

• Address
  Address

• Date of Birth

• Age

• National Insurance Number

• Employer

• Occupation

• Contact Details

Section 1 - Personal Details- Witness Information

• Witness 1 - Name

• Witness 1 - Address
  Address

• Witness 1 - Employer

• Witness 1 - Occupation

• Witness 2 - Name

• Witness 2 - Address
  Address

• Witness 2 - Employer

• Witness 2 - Occupation

• Witness 3 - Name

• Witness 3 - Address
  Address

• Witness 3 - Employer

• Witness 3 - Occupation

Section 2 - Incident Type

• Incident Type

  Select Fatality Major Injury Lost Time Accident > 7 Days Lost Time Accident < 7 Days First Aid / Non-Absence Event Near Miss Dangerous Occurrence Unsafe Act Services Damage Other

  • Fatality
  • Major Injury
  • Lost Time Accident > 7 Days
  • Lost Time Accident < 7 Days
  • First Aid / Non-Absence Event
  • Near Miss
  • Dangerous Occurrence
  • Unsafe Act
  • Services Damage
  • Other

Section 2 - Incident Category

• Incident Category

  Select Animals / Pests Asbestos Chemical/Substance Electricity Environmental Fire Manual Handling Miss or Slip/Trip/Fall on same level Miss or Fall from Height Miss/Strike by Falling Object Miss/Strike by Flying Object Miss/Strike by Moving Object Miss/Strike by Moving Plant/Vehicle Strike Against Stationary Object Violence Weather Other

  • Animals / Pests
  • Asbestos
  • Chemical/Substance
  • Electricity
  • Environmental
  • Fire
  • Manual Handling
  • Miss or Slip/Trip/Fall on same level
  • Miss or Fall from Height
  • Miss/Strike by Falling Object
  • Miss/Strike by Flying Object
  • Miss/Strike by Moving Object
  • Miss/Strike by Moving Plant/Vehicle
  • Strike Against Stationary Object
  • Violence
  • Weather
  • Other

Section 2 - Incident Information

• Date of injured/involved party site induction

• Date and Time of Incident

  Date

• Weather conditions at time of incident

• Location of incident

• Description of Task/Activity taking place

• In a Risk/COSHH Assessment/ Method Statement in place for the operation?

  Yes

  No

  N/A

• Is a permit to work required for the operation

  Yes

  No

  N/A

• Are persons involved in incident authorised & trained for tasks being carried out?

  Yes

  No

  N/A

• Details of Plant/Equipment being used

• Details of PPE/RPE/Safety Equipment being worn by Injured Party

  Select Safety Helmet Safety Boots/Footwear Overalls/Workwear Hi-Visibility Vest/Jacket/Clothing Gloves Safety Glasses Safety Goggles Face Shield/Visor Disposable Face Mask Half Face Respirator Full face Respirator/Hood Ear Defenders Disposable Ear Plugs Safety Harness c/w Fall Arrest Lanyard Safety Harness c/w Fall Restraint Lanyard

  • Safety Helmet
  • Safety Boots/Footwear
  • Overalls/Workwear
  • Hi-Visibility Vest/Jacket/Clothing
  • Gloves
  • Safety Glasses
  • Safety Goggles
  • Face Shield/Visor
  • Disposable Face Mask
  • Half Face Respirator
  • Full face Respirator/Hood
  • Ear Defenders
  • Disposable Ear Plugs
  • Safety Harness c/w Fall Arrest Lanyard
  • Safety Harness c/w Fall Restraint Lanyard

• Is PPE/RPE suitable for task & in good condition?

  Yes

  No

  N/A

• Insert Description of Accident/Incident/Near Miss Event

• Are photographs of incident scene attached

  Yes

  No

• What do you believe to be the primary causal factor of the incident?

• Insert details of corrective action taken/required to prevent recurrence

Section 3 - Medical Information

• We're any injuries sustained from this event?

  Yes

  No

• Was First Aid treatment needed/given?

  Yes

  No

• If the answers to both questions above is NO then the rest of this section does not need to be completed

• If First Aid treatment was given please provide details

• Did the Injured Party return to work after treatment?

  Yes

  No

• If YES at what time?

• Will Injured Party be absent for more than 7 days?

  Yes

  No

• Did Emergency Services attend the incident?

  Yes

  No

• If Yes please insert details

• Nature of Injury

  Select Abrasions/Scrapes Amputation Broken Bone Bruising Burn (Heat) Burn (Chemical) Concussion Crush Cut/Laceration Dislocation Hernia Ill Health Muscular (Sprain/Strain) Puncture Other

  • Abrasions/Scrapes
  • Amputation
  • Broken Bone
  • Bruising
  • Burn (Heat)
  • Burn (Chemical)
  • Concussion
  • Crush
  • Cut/Laceration
  • Dislocation
  • Hernia
  • Ill Health
  • Muscular (Sprain/Strain)
  • Puncture
  • Other

• Provide description of injuries

• Touch diagram to Indicate any injured or affected area(s) of the body

  Drawing

Section 4 - Confirmation

• Is the incident RIDDOR reportable?

  Yes

  No

  TBC

• Report Author Signature

  Sign

• RIDDOR Reference Number (if applicable)

Section 5 - Supporting Evidence Document Checklist

• Have the following documents been submitted with this report?

• Site induction records

  Yes

  No

  N/A

• Site sign in/out register

  Yes

  No

  N/A

• Contacted RAMS appraisal form

  Yes

  No

  N/A

• Method Statement and Risk/COSHH assessments for task/activity

  Yes

  No

  N/A

• Permit to Work

  Yes

  No

  N/A

• Personnel training records

  Yes

  No

  N/A

• Plant/Equipment inspection records

  Yes

  No

  N/A

• Photographs of incident area

  Yes

  No

  N/A

• Completed Witness Statements

  Yes

  No

  N/A

• Relevant statutory inspection records

  Yes

  No

  N/A

• Sub-Contractor reports

  Yes

  No

  N/A

• Safety reports

  Yes

  No

  N/A

• Other relevant documents

  Yes

  No

  N/A