BPL Incident Report Form

• Document No.

• BPL Facility

• Conducted on

  Date

Details of person involved

• Full name

• Contact address and postcode

• Gender

  Male

  Female

• Age

• Reason for using the facilities

  Employee

  Member of public

  Contractor (incl. Cofely)

  Other

• If 'Other' please specify

About the incident

• Where did the incident occur?

• When was the incident first reported?

  Date

• Description of the environmental conditions (e.g. condition of floor, lighting)

• Photos of the environmental conditions

  Media

• Description of the events leading up to the incident

• Description of the roles played by all people involved

• List of substances, machinery or equipment involved

• Name(s) of any witness(es) to the incident

• Name of the member of staff supervising the area

• Name and job title of the person the incident was first reported to

• Was this a near-miss or was there an injury? (Please complete the appropriate section below)

  Injury

  Near-miss

Near-miss

• Description of the near-miss (Full description of the procedures followed)

• Corrective actions (What should be done or has been done to prevent a reoccurrence of this near-miss)

Injury

• Type of injury (e.g. Cut, bruise, fracture)

• What part of the body was injured?

• What happened following the injury? (Select all that apply)

  Select Received first aid treatment Continued using the facilities Required hospital treatment Left the facilities

  • Received first aid treatment
  • Continued using the facilities
  • Required hospital treatment
  • Left the facilities

• Name and address of doctor surgery or hospital (if referred for further treatment)

• How did the injury occur? (Please select the option which best describes what happened)

  Select Needle/stick/sharp contact with moving machine or machined material Hit by moving object Hit by moving vehicle Injured while handling, lifting or carrying Slipped, tripped or fell Fell from height Drowned or asphyxiated Exposed to or in contact with harmful substance Exposed to fire Contact with electricity or an electrical discharge Injured by an animal or insect Injured by another person Other

  • Needle/stick/sharp
  • contact with moving machine or machined material
  • Hit by moving object
  • Hit by moving vehicle
  • Injured while handling, lifting or carrying
  • Slipped, tripped or fell
  • Fell from height
  • Drowned or asphyxiated
  • Exposed to or in contact with harmful substance
  • Exposed to fire
  • Contact with electricity or an electrical discharge
  • Injured by an animal or insect
  • Injured by another person
  • Other

• If 'Other' please describe what happened

• Nature of first aid given and by who

• Has RIDDOR been completed?

  Yes

  No

  N/A

Signatures

• Person who completed this form

  Sign

• Injured person

  Sign

• Duty Officer

  Sign