Accident Report (Pt 1) Open & Initial Response

• 

• Site Name

  Select

• Please select region

  Select North Central South Fresh Direct KFF Medina NDC

  • North
  • Central
  • South
  • Fresh Direct
  • KFF
  • Medina
  • NDC

• Investigation Manager

• Injured Person's Name

• Severity status

  Remained at Work

  Went home

• Please select department

  Warehouse

  Distribution

  Admin

• Date and time reported

  Date

• Incident date

  Date

• Incident time

  Date

• Incident number

Please go to phase 1 incident response

• Incident type - On Site/ Off Site

  On site accident

  Off site accident

Summary of Incident - Ensure driver is in a safe place to continue the call (not stood in road).

• Are you in a safe place, where are you making this call from

• Has the emergency services been called

  Yes

  Not Required

  No

• Which servies

• Brief summary of incident

• If on customers premises - Has the customer been informed of the accident

  Yes

  No

  Not on Customer Premises

• Why not?

• Can you take photo's of the scene (use the see it sort it app on hand held)

  Yes

  No

• Why Not

• Has the scene been altered since the incident

  Yes

  No

• Why was the scene altered

The Injured Person, please ensure the welfare of the individual before continuing.

• Was the injury to the head

  Yes

  No

• Please tell me if you are suffering from the following - Feeling tired, sick, headache, dizziness, blurry vision.

  Yes

  No

• you may be feeling the effects of concussion, please go to customers premises so not alone, we will phone the customer.

• Has the injured colleague receive first aid

  Yes

  No

  Not on Customer Premises

• If no why not

• Please can you take a photo of your injury

• On return to site please see your manager to complete an injured persons statement

Supporting comments

• Supporting Comments

Signature of Incident Manager

• Add signature

  Sign

Submit

• Select site to submit this initial accident report to the accident notification group

  Select Aylesford Bodmin Bridgend Brighton Ashford Corby Bodelwyddan Deeside Dundee Durham Eastleigh Grantham Harlow Hemsworth Inverness Newark Newhouse Covent Garden Peterlee Portbury Premier park Reading Ripon Tamworth Thetford Warrington Wigan Bicester Dagenham KFF Aylesford KFF Witney Medina IOW Medina Southampton

  • Aylesford
  • Bodmin
  • Bridgend
  • Brighton
  • Ashford
  • Corby
  • Bodelwyddan
  • Deeside
  • Dundee
  • Durham
  • Eastleigh
  • Grantham
  • Harlow
  • Hemsworth
  • Inverness
  • Newark
  • Newhouse
  • Covent Garden
  • Peterlee
  • Portbury
  • Premier park
  • Reading
  • Ripon
  • Tamworth
  • Thetford
  • Warrington
  • Wigan
  • Bicester
  • Dagenham
  • KFF Aylesford
  • KFF Witney
  • Medina IOW
  • Medina Southampton

Summary of Incident

• Brief summary of incident

• Please take photos of the scene (if using desk top, upload them to this pack)

  Media

• Has the scene been altered since the incident

  Yes

  No

• Why was the scene altered

The Injured Person

• Has the injured colleague receive first aid

  Yes

  No

• If no why not

• Has the injured colleague remained at work

  Yes

  No

• Did the injured person go to hospital

  Yes

  No

• Did the injured person go home

  Yes

  No

• Take Photo of injury

  Media

• If possible take a comparison photo (i.e Other arm/ leg)

  Media

• Has an Injured persons statement been taken

  Yes

  No

• Please explain why

PPE

• Was PPE being worn at the time of the incident

  Yes

  No

• Please explain why not

• Are you able to take photo of their gloves

  Yes

  No

• Please explain why

• Add media

  Media

• Are you able to take photo of their Boots

  Yes

  No

• Please explain why

• Add media

  Media

• Are you able to take a photo of other PPE being worn at time of incident

  Yes

  No

• Please explain why

• Add media

  Media

Work Place

• Exact location of incident

• Activity in work area at time of incident

• Witnesses to incident

  Yes

  No

• Are statements being collected

  Yes

  No

• Condition of work place

  Good

  Fair

  Poor

• Please describe the reason why

• Name of supervisor of area

Equipment & MHE

• Was Equipment/ MHE being used or in use during incident

  Yes

  No

• List the equipment/ MHE being used including fleet number or Serial number

• Has the Equipment/MHE been isolated

  Yes

  No

• If no please explain why not

• Please take photo of piece equipment

  Media

Hampton Knight

• Was Hampton knight Called to site

  Yes

  No

• If No please explain why not

Any other info

• Please add any additional information or photographs that you feel is relevant to this incident

Supporting comments

• Supporting Comments

Signature of Incident Manager

• Add signature

  Sign

Submit

• Click to submit this initial accident report to GM

  Select Aylesford Bodmin Bridgend Brighton Ashford Corby Bodelwyddan Deeside Dundee Durham Eastleigh Grantham Harlow Hemsworth Inverness Newark Newhouse Covent Garden Peterlee Portbury Premier park Reading Ripon Tamworth Thetford Warrington Wigan Bicester Dagenham KFF Aylesford KFF Witney Medina IOW Medina Southampton

  • Aylesford
  • Bodmin
  • Bridgend
  • Brighton
  • Ashford
  • Corby
  • Bodelwyddan
  • Deeside
  • Dundee
  • Durham
  • Eastleigh
  • Grantham
  • Harlow
  • Hemsworth
  • Inverness
  • Newark
  • Newhouse
  • Covent Garden
  • Peterlee
  • Portbury
  • Premier park
  • Reading
  • Ripon
  • Tamworth
  • Thetford
  • Warrington
  • Wigan
  • Bicester
  • Dagenham
  • KFF Aylesford
  • KFF Witney
  • Medina IOW
  • Medina Southampton

• Have the captured IP and first Aider Statements been sent with the Initial response to all necessary escalations with this report

  Yes

  No

  N/A