Title Page
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Document No.
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Accident / Incident/ Near Miss Report
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Client / Site
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Conducted on
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Prepared by
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Location
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Allma Site Supervisor
Declaration
Declaration
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This report contains the opinions, conclusions and recommendations of the author based entirely on the information available to the author at the time of writing. The author believes the content of this document to be accurate at the time of issue, however, it is not being presented as the definitive or final version. Any additional information relative to the subject matter, which may become accessible in future, has the potential to modify the author’s understanding of circumstances, which could subsequently necessitate further review, consideration and/or revision to some or all, of the information, observations and conclusions contained herein. The provision of this report does not mean that our investigations into this matter are closed, however as health, safety and well-being is of paramount importance, we have decided not to delay the production and circulation of this document. We fully recognise that investigation by other parties; inquiries by official agencies and others; proceedings in public inquiry and interest etc. could, in due time, possibly produce further information which hypothetically could result in one or more of the observations herein presented, opinions herein expressed, or recommendations made herein, being considered inaccurate or inappropriate. That is a potential risk which Allma Construction feels is justified to take in the best interests of public health, safety, and well-being. The author does not accept responsibility for any consequences arising from the use of the information within this document.
Report
Section 1 - Personal Details - Report Author
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Report completed by
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Position
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Date & Time
Section 1 - Personal Details - Involved/Injured Party Information
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Is there an involved/injured party?
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Member of Public
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Name
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Address
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Date of Birth
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Age
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National Insurance Number
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Employer
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Occupation
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Contact Details
Section 1 - Personal Details- Witness Information
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Were there any witnesses to this event?
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Witness 1 - Name
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Witness 1 - Address
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Witness 1 - Employer & Occupation
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Were there multiple witnesses to this event?
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Witness 2 - Name
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Witness 2 - Address
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Witness 2 - Employer & Occupation
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Witness 3 - Name
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Witness 3 - Address
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Witness 3 - Employer & Occupation
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Witness 4 - Name
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Witness 4 Address
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Witness 4 - Employer & Occupation
Section 2 - Incident Type
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Incident Type
- Abrasions/Scrapes
- Amputation
- Broken Bone
- Bruising
- Burn (Heat)
- Burn (Chemical)
- Concussion
- Crush
- Cut/Laceration
- Dislocation
- Hernia
- Ill Health
- Muscular (Sprain/Strain)
- Puncture
- Services Damage
- Property Damage
- Other
Section 2 - Incident Category
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Incident Category
- Animals / Pests
- Asbestos
- Chemical/Substance
- Electricity
- Environmental
- Fire
- Gas
- IT/Comms
- 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
- Water
- Weather
- Other
Section 2 - Incident Information
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Date and Time of Incident
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Weather conditions at time of incident
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Location of incident
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Description of Task/Activity taking place
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Was this a planned activity?
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Was this an authorised activity?
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Is there a Risk Assessment/ Method Statement in place for the operation?
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Is a permit to work required for the operation?
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Details of Plant/Equipment being used
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Insert Description of Accident/Incident/Near Miss/Damage Event
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Are photographs of incident scene attached
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What do you believe to be the immediate cause of the incident (the immediate events and/or conditions which caused the event to happen)?
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What do you believe to be the underlying/contributing causal factors (the events and/or conditions which created the circumstances enabling the immediate cause to happen)?
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What do you believe to be the primary (root) causal factor of the incident? ?
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Insert details of initial corrective action taken/required to prevent recurrence
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Detail any further action need to be taken to address the causes of this incident and prevent recurrence?
Section 3 - Medical Information
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Was any injury sustained from this event?
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Nature of Injury
- Abrasions/Scrapes
- Amputation
- Broken Bone
- Bruising
- Burn (Heat)
- Burn (Chemical)
- Concussion
- Crush
- Cut/Laceration
- Dislocation
- Hernia
- Ill Health
- Muscular (Sprain/Strain)
- Puncture
- Services Damage
- Property Damage
- Other
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Provide description of injuries
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Touch diagram to Indicate any injured or affected area(s) of the body
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If First Aid treatment was given please provide details
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Did the Injured Party return to work after treatment?
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If YES at what time?
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Will Injured Party be absent for more than 7 days?
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Did Emergency Services attend the incident?
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If Yes please insert details
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Did the injured party receive medical assistance or attend hospital?
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If Yes, please insert details (if known)
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Note - if there were no injuries sustained then the supplementary questions within the drop down menu in this section do not require to be completed and will not appear.
Section 4 - Confirmation
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Is the incident RIDDOR reportable?
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Report Author Signature
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RIDDOR Reference Number (if applicable)
Section 5 - Supporting Evidence Document Checklist
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Have the following documents been submitted with this report?
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Method Statement and Risk/COSHH assessments for task/activity
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Services Drawings/Information
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Permit to Work
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Plant/Equipment inspection records
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Photographs of incident area
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Completed Witness Statements
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Other relevant documents (Specify)
