Information
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Name of Injured Person
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Conducted on
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Prepared by
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Location
1. About the Injured Person
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Name of Injured Person
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Job Title of Injured Person
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Please advise job title
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Supervisor of Injured Person
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Is the supervisor aware of the incident?
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Please copy the Supervisor into the report when sending to the Compliance Department
2. About the incident
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Date of the Incident
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Time of Incident
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Address of Incident
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Explain what happened? (including type of work being carried out, machinery, substance or article involved) Please take photos where possible.
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What injury was sustained?
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What is the nature of the incident?
- Animal
- Drown
- Electricity
- Explosion
- Fall
- Fire
- Harmful Substance
- Manual Handling
- Other
- Slips & Trips
- Strike Against
- Struck By Falling Object
- Trapped By Collapse
- Vehicle
- Violence
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Was first aid necessary?
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What first aid was administered?
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Status of injured person (IP)
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Please advise status of IP
3. Injured Person Statement
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Please provide full details of what happened (including what, who, when, how and why)
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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.
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Injured Person Signature if present
4. Witnesses Details
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Were there any witnesses to the incident?
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Please proceed to the next section.
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Witness 1 Name
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Witness 1 Statement
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Were there anymore witnesses?
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Witness 2 Name
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Witness 2 Statement
5. Risk
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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)
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If all necessary documents and procedures had been followed and the correct equipment used for the job, would the job have been controlled?
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Did the means of control fail?
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Explain why they failed
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Was the injured person aware of the risks involved?
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Were standard working practices being carried out?
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Please give details of the relevant training and supervision.
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Was there an urgency to get the job done?
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Explain why
6. Conclusions
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Are you satisfied there was effective risk control?
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Are you satisfied that all measures of control were identified?
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Are you satisfied that you ensured that all control measures were adopted?
7. Corrective Actions
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Please advise what corrective actions you have taken (removed defective equipment etc)
