Title Page
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Site/project reference
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Report completed by
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Location
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Form reference. Also add any other attached form no’s to this.
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Date & time this form is filled in
Incident details
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Name of person making report
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Position
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Telephone number
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Date and time of Incident
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What was the location of the incident? Give details.
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Name of Person involved in the incident (if more than one person then complete another form and attach to this)
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About the incident. Please give as much information as possible about how the incident occurred, its location, weather, inside/outside etc…
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Name:
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Telephone number:
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Was the injured person an Employee / Agency / Visitor / Member of public?
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About the injury. Please give as much information as possible about the injuries sustained.
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What was the injury? (eg fracture, laceration etc)
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What part of the body was injured?
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ABOUT THE KIND OF INCIDENT. Identify below (multiple options can be selected)
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Manual handling injury
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Injury to any part of the body using hand tools
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Injury to any part of the body using power tools
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Contact with moving machinery or material being machined
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Hit by a moving, flying or falling object
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Hit by a moving vehicle
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Injured while handling, lifting or carrying
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Hit by something fixed or stationary
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Slipped, tripped or fell on the same level
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Fell from a height
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How high was the fall?
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Trapped by something collapsing
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Drowned or asphyxiated
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Exposed to, or in contact with, a harmful substance
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Exposed to fire
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Exposed to an explosion
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Contact with electricity or an electrical discharge
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Injured by an animal
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Physically assaulted by a person
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Any other kind of accident
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Describe what happened. (Give as much details as you can i.e. the name of any substance involved, type of machine involved, the events that led to the incident, the part played by people. If it was a personal injury, give details of what the person was doing. Describe any action that has since been taken to prevent a similar incident. Use a separate piece of paper if you need to.)
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Was first aid required/provided?
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Who administered the first aid? (give details)
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What first aid was given?
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Were any medicines/pain killers taken/administered (medicine or pain killers should not be administered by untrained/unauthorised persons) if yes then give details below.
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Details of medicines/pain killers used
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Signature of person completing this report
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Signature of person involved in the incident (they must read all of this report and are signing to say all information included in it is correct)
