Accident / Incident report

• Site conducted

  Select

• Conducted on

  Date

• Prepared by

• Location
  Address

• Incident Catagory

  Major

  Minor

Injured Person Details

• Injured persons Name

• Injured Persons Address

• Injured Persons Phone Number

• Photo of Induction Record

  Media

• Photo of signing in sheet for the day of the incident.

  Media

• Photo showing Injured Person has signed up to the relevant Safe System of Work

  Media

Incident Details

• Date and Time of incident

  Date

• Description of what has happened

• Detailed description of location of Incident.

• Photo of injury

  Media

• Photo of incident location

  Media

Treatment

• Treatment given / received.

  Select Gone to hospital via ambulance Taken self to hospital/ taken to hospital On site first aid given Advised to attend GP/ urgent care None

  • Gone to hospital via ambulance
  • Taken self to hospital/ taken to hospital
  • On site first aid given
  • Advised to attend GP/ urgent care
  • None

• RIDDOR Status / Lost time

  Select Death/ Loss of life Broken Bones (other than toes and fingers) More than 7 days off work Less than 7 days off work Continued working

  • Death/ Loss of life
  • Broken Bones (other than toes and fingers)
  • More than 7 days off work
  • Less than 7 days off work
  • Continued working

Witness

• Witness Name

  Yes

  No

  N/A

• Witness address

  Yes

  No

  N/A

• Witness Phone Number

  Yes

  No

  N/A

• Witness Signature

  Sign

• Does the incident are need cordoning off

  Yes

  No

• Has the incident area been cordoned off

  Yes

  No

• Photo of area corded off

  Media

• Have you informed your line Manager

  Yes

  No

• Have you informed Health and Safety

  Yes

  No
Additional Information

• Comments that you feel are relevant

• Photos relating to comment

  Media

Photos of Additional document that are relavant

• take a photo of the document

  Media