Information
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Document No.
What is being reported
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A near miss or dangerous occurrence
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Damage to a building or property
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An incident resulting in injury
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A violent incident
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A case of work related ill health
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When did the incident occur
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Client / Site
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Wide area picture of site
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Prepared by
Part A
PART A - To be completed by the person reporting the incident or the injured person
Contact details of person filling in this form including tel & email address
Type of Accident
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- slip
- trip
- fall
- MH
- impact
- cut/ laceration
- doors
- lift
- property
Description of incident
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What time & date did the incident occur?
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What was the exact location of the incident. Include address, building or grid reference and room name/number.
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What happened? Describe the incident. Give as much information as possible. Include what was happening at the time the incident occurred.
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Relevant photos or video
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Date & time of videos or video
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If this was a violent incident, what was the nature of the incident?
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Weather Conditions eg Rain, sleet, snow, dry
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Visibility e.g. Fog, haze, dark, overcast etc
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Surface type
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Type of footwear person was wearing
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Was the footwear in good condition?
Police involvement
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Were the police informed?
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Date anytime police informed
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How were the Police informed?
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Crime number
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Notes
Injury details
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Describe the exact parts of the body injured
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Full name of injured person
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Date of birth
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Male or Female
- Male
- Female
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Home address
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Contact number
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Employer address if contractor or agency
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Next of kin name and tel
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Has the area been inspected and is safe
Treatment given
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Details of Treatment
Classification of injured person
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Employee
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Member of public
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Agency worker
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Contractor
Witness information
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We're there any witnesses to this incident?
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Witness name
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Witness contact number and email address
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Witness postal address
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Statement of witness to accident/incident
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Witness statement
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Witness statement(if not scanned in above)
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Add signature
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Any photos taken by witnesses
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Was there CCTV footage captured, what is shown
Report
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To Whom was the Incident reported to at site
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When was the incident reported
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Select date
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We're any other agencies or external bodies informed. If so who and when?
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Any additional Information
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Who made this report
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Add signature
Part B
To be completed by the relevant responsible person or manager or event organiser
RIDDOR reporting - if anyone was injured were they....
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An employee who lost consciousness or needed resuscitation
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An employee who suffered a major injury
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An employee who was hospitalised for more than 24 hours
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An employee who was absent for more than 7 consecutive days
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A member of the public, visitor etc, who was taken to hospital direct from the site of the incident
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Has the incident been reported under RIDDOR
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If reported under RIDDOR, when?
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If reported under RIDDOR, who made the report?
Disposal
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What initial treatment was given
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What happened to the casualty
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How were they transported and who by
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If the person went to a medical facility, which one.
Causes
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Detail any potential causes of the incident that have been identified during the initial investigation
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Relevant media
Actions taken to prevent recurrence
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Detail all actions taken
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Is a further detailed investigation required?
Media
Photos
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Add media
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Add media
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Add media
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Videos
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Add media
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Add media
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Add media
Voice notes
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Add media
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Add media
