Information
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Document No.
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Audit Title
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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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Personnel
This Form Must Be Completed Immediately Following The Incident By An Employee
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Date Reported:
Person Involved:
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Surname:
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Forename:
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Address:
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Date of Birth:
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Contact Number:
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Employee; Contractor; Visitor; Public; Adult; Child;
Details / Names & Addresses Of Any Witnesses
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Surname:
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Forename:
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Address:
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Contact No:
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Employee; Contractor; Visitor; Public;
Accident Details
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Exact Location Of Accident
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Photographs of the scene:
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Include Sketch Plan if Required:
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Date / Time of Accident
Which of the following best describes the accident?
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Accident Injury; Near Miss; Illness; Violent Incident; Accidental Property Loss / Damage
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Did the person suffer injury or ill-Health
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If Yes, what part of the body was affected?
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Photographs of injuries
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If Illness Please Specify:
Which of the following best describes the injury sustained?
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Select relevant option
- Not Applicable
- Bruising
- Scald/burn
- Concussion
- Laceration
- Abrasion
- Swelling
- Sprain
- Fracture
- Dislocation
- Head Injury
- Other
Which of the following best describes the cause of the injury?
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Select relevant option.
- Not Applicable
- Slip, trip or fall
- Contact with hot substance
- Struck against object
- Manual handling
- Struck by moving vehicle
- Exposure to or contact with a harmful substance
- Injured by an animal
- Fall from height
- Cut by a sharp object
- Struck by a moving/falling object
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Select relevant option
- Not Applicable
- Contact with moving machinery or material being moved
- Trapped by something collapsing or overturning
- Exposure to fire
- Contact with electricity or an electrical discharge
- Exposure to explosion
- Other kind of accidents
Which of e following best describes the agent involved?
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Machinery; Vehicle or associated equipment/machinery; Process plant, pipe work or bulk storage; Gas, vapour, dust, fume or oxygen deficient atmosphere; Live animal; Floor, ground, stairs or any working surface; Ladder or scaffolding; Electrical supply cable, wiring apparatus or equipment; Portable power or hand tools; Other machinery; Pathogen or other infected material; Moveable container or package of any kind; Building, work engineering structure or excavation/underground; Entertainment or sporting facilities or equipment; Any other agent or
- Not Applicable
- Machinery
- Vehicle or associated equipment/machinery
- Process plant, pipe work or bulk storage
- Gas, vapour, dust, fume or oxygen deficient atmosphere
- Live animal
- Floor, ground, stairs or any working surface
- Ladder or scaffolding
- Electrical supply cable, wiring apparatus or equipment
Treatment Received?
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First Aid; None; Ambulance; Doctor
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Who dealt with the injured person?
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Name:
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Contact No:
Give an account of the incident/accident
Describe any damaged property if applicable and detail the damage
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(Article Description and make, age and condition prior to incident)
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Photographs of Items Involved:
Declaration
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I hereby declare that the information given is true to the best of my knowledge and belief:
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Name:
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Job Description:
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Contact Information:
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Date Submitted::
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Signature:
