Information

  • Name of Injured Person

  • Conducted on

  • Prepared by

  • Location

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

  • Date of 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?

  • What is the nature of the incident?

  • 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.

  • Injured Person Signature if present

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

5. Risk

  • 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?

  • Explain why

6. Conclusions

  • 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)

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.