1. About the Injured Person
Name of Injured Person
Job Title of Injured Person
Please advise job title
Supervisor of Injured Person
Is the supervisor aware of the incident?
Please copy the Supervisor into the report when sending to the Compliance Department
2. About the incident
Time of Incident
Address of Incident
Explain what happened? (including type of work being carried out, machinery, substance or article involved) Please take photos where possible.
What injury was sustained?
- Harmful Substance
- Manual Handling
- Slips & Trips
- Strike Against
- Struck By Falling Object
- Trapped By Collapse
Was first aid necessary?
What first aid was administered?
Status of injured person (IP)
Please advise status of IP
3. Injured Person Statement
Please provide full details of what happened (including what, who, when, how and why)
This statement has been made from my own knowledge. I have been offered the opportunity to make any amendments I wish before signing it. I believe that the statement is true. I consent to this statement being disclosed to anyone with reasonable grounds to require it.
4. Witnesses Details
Were there any witnesses to the incident?
Please proceed to the next section.
Witness 1 Name
Witness 1 Statement
Were there anymore witnesses?
Witness 2 Name
Witness 2 Statement
Provide details of the specific Risk Assessments, Method Statements, COSHH Assessments and company procedures which relates to the task being carried out (e.g RA1)
If all necessary documents and procedures had been followed and the correct equipment used for the job, would the job have been controlled?
Did the means of control fail?
Explain why they failed
Was the injured person aware of the risks involved?
Were standard working practices being carried out?
Please give details of the relevant training and supervision.
Was there an urgency to get the job done?
Are you satisfied there was effective risk control?
Are you satisfied that all measures of control were identified?
Are you satisfied that you ensured that all control measures were adopted?
7. Corrective Actions
Please advise what corrective actions you have taken (removed defective equipment etc)