ICT Andover 5a. Accident / Incident Form

• Date & Time Completed

  Date

• Type Of Report

  Select Accident Incident Near Miss Work Related Accident Aggression To Staff

  • Accident
  • Incident
  • Near Miss
  • Work Related Accident
  • Aggression To Staff

Details about the casualty / Person affected

• Name

• Address

• Date Of Birth

• If the casualty is under 18 then ensure parents are notified

• Contact Number

Location Of Accident / Incident

• Select Location Of Accident

  Therapy Room 1

  Therapy Room 2

  Main Area

  Non Valley Leisure Area

• Activity Taking Place

Injury Sustained, Description As To What Happened & First Aid Given

• Injury Sustained

  Select Asthma/Diabetes Slip/Trip/Fall Bruise/Bump Head Injury Nosebleed Cut/Graze Fracture/Dislocation CPR Other

  • Asthma/Diabetes
  • Slip/Trip/Fall
  • Bruise/Bump
  • Head Injury
  • Nosebleed
  • Cut/Graze
  • Fracture/Dislocation
  • CPR
  • Other

• Were The Emergency Service Called

  Yes

  No

• Crime Reference (If Applicable) - Write N/A If Not

• Description As To What Happened

• Please Mark Body Parts Affected (If Applicable)

  Drawing

• Please Mark Pain Threshold (If Applicable)

  Drawing

• First Aid Given / Witnesses / Outcome

• Head Injury Form Completed?

  Yes

  No

  N/A

• First Aid Given By

• I Confirm That I Am Satisfied With The First Aid Given And The Details Recorded Are Correct And Accurate. Name & Sign

  Sign

• Form Completed By & Signed

  Sign

Post First Aid

• What Items Were Used From The First Aid Kit

• Has The First Aid Kit Been Restocked & Resealed

  Yes

  No

  N/A

Managers Use Only

• Was There Any Defects, Equipment Involved; If So Was It Defective?

  Yes

  No

• Is CCTV Available, If So Has It Been Burnt?

  Yes, But Not Required

  Yes, Burnt & Saved

  No Coverage

• Further Investigation Required?

  Yes

  No

• Is The Incident RIDDOR Reportable?

  Yes

  No

• Record RIDDOR Reference No.

• Any Further Information Needed - Record N/A If Not

• Managers Name & Signature

  Sign