HSM Incident Report Form

• Incident No.

• Document No.

What is being reported

• A near miss or dangerous occurrence

• Damage to a building or property

• An incident resulting in injury

• A violent incident

• A case of work related ill health

• When did the incident occur

  Date

• Client / Site

• Wide area picture of site

  Media

• Prepared by

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

• Select slip trip fall MH impact cut/ laceration doors lift property

  • slip
  • trip
  • fall
  • MH
  • impact
  • cut/ laceration
  • doors
  • lift
  • property

• Other

Description of incident

• What time & date did the incident occur?

  Date
• What was the exact location of the incident. Include address, building or grid reference and room name/number.
  Address

• What happened? Describe the incident. Give as much information as possible. Include what was happening at the time the incident occurred.

• Relevant photos or video

  Media

• Date & time of videos or video

  Date

• If this was a violent incident, what was the nature of the incident?

• Weather Conditions eg Rain, sleet, snow, dry

• Visibility e.g. Fog, haze, dark, overcast etc

• Surface type

• Type of footwear person was wearing

• Was the footwear in good condition?

Police involvement

• Were the police informed?

  Safe

  At Risk

  N/A

• Date anytime police informed

  Date

• How were the Police informed?

  999

  101

  In Person

  3rd Party

• Crime number

• Notes

Injury details

• Describe the exact parts of the body injured

• Full name of injured person

• Date of birth

• Male or Female

  Select Male Female

  • Male
  • Female
• Home address
  Address

• Contact number

• Employer address if contractor or agency
  Address

• Next of kin name and tel

• Has the area been inspected and is safe

  Safe

  At Risk

  N/A

Treatment given

• none

  first Aid

  Doctor

  Ambulance

  Other emergency services

• Details of Treatment

Classification of injured person

• Employee

• Member of public

• Agency worker

• Contractor

Witness information

• We're there any witnesses to this incident?

  Yes

  No

  NA

• Witness name

• Witness contact number and email address

• Witness postal address
  Address

• Statement of witness to accident/incident

  Yes

  No

  N/A

• Witness statement

  Media

• Witness statement(if not scanned in above)

• Add signature

  Sign

• Statement 1

• Add signature

  Sign

• Statement 2

• Add signature

  Sign

• Statement 3

• Add signature

  Sign

• Statement 4

• Add signature

  Sign

• Any photos taken by witnesses

  Media

• Was there CCTV footage captured, what is shown

  Yes

  No

  N/A

• What was seen on CCTV

Report

• To Whom was the Incident reported to at site

• When was the incident reported

• Select date

  Date

• We're any other agencies or external bodies informed. If so who and when?

• Any additional Information

• Who made this report

• Enter any other relevant information

  Sign

To be completed by the relevant responsible person or manager or event organiser

RIDDOR reporting - if anyone was injured were they....

• An employee who lost consciousness or needed resuscitation

• An employee who suffered a major injury

• An employee who was hospitalised for more than 24 hours

• An employee who was absent for more than 7 consecutive days

• A member of the public, visitor etc, who was taken to hospital direct from the site of the incident

• Has the incident been reported under RIDDOR

  Yes

  No

  NA

• If reported under RIDDOR, when?

  Date

• If reported under RIDDOR, who made the report?

Disposal

• What initial treatment was given

  First Aid

  Hospital

  CPR

• What happened to the casualty

  back to event

  home

  hospital

• How were they transported and who by

• If the person went to a medical facility, which one.

Causes

• Detail any potential causes of the incident that have been identified during the initial investigation

• Relevant media

  Media

Actions taken to prevent recurrence

• Detail all actions taken

• Is a further detailed investigation required?

  Yes

  No

  NA

Photos

• Add media

  Media

• Add media

  Media

• Add media

  Media

• Add media

  Media

• Add media

  Media

• Add media

  Media

• Add media

  Media

• Add media

  Media

Videos

• Add media

  Media

• Add media

  Media

• Add media

  Media

Voice notes

• Add media

  Media

• Add media

  Media