Information
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Site conducted
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Conducted on
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Nature of report:
Details
Details of Incident/Accident/Near Miss
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Type of Incident/Accident:
- Incident
- Accident
- Injury
- Theft/Attempt Theft
- Assault
- Near Miss
- Unsafe Act / Condition
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Has this incident / accident caused harm to a member of Aston Services Group?
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Who has been hurt or injured from ASG?
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Person Completing this Report
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Manager/Supervisor on Site at time of incident/accident. (If no supervisor/manager on duty, add N/A)
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Person who Reported Incident/Accident (ASG employee/Control room operative/aggrieved/3rd party)
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Location of incident/Accident/Near miss
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Insert Photo of Accident/Incident location.
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Name of person(s) involved/Aggrieved/Suspect, including contact details (Phone/email/address)
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Witnesses:
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Witness(es), names and contact details.
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Date and time of Incident
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Management notified at time of incident/accident or as soon as practicable.
- SSC
- SSM
- Centre Manager
- Deputy Manager
- Ops Manager
- ROM
- Centre administrator
- Director
- No. N/A - Add reason
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Is CCTV available/Relevant
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Has a copy been saved to a safe working area (drive/USB/Disc) for future review.
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Where?
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Was First Aid Required/Administered, <br>Where this was a slip/trip/fall, ensure photographic evidence is obtained of: <br>FOOTWEAR, <br>LOCATION, <br>WEATHER<br>SURFACE CONDITIONS<br>OBSTRUCTIONS<br>ANY ADDITIONAL INFORMATION REGARDING DEFECTS ETC.
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Who administered first aid:
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What first aid was required/administered? (Add details)
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Emergency services called/required?
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Add details: Names, collar numbers etc.
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Add crime reference number if provided:
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Arrival date and time
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Departure date and time
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Is there any Property involved? Damage/Stolen/Retrieved
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Add details: Names, collar numbers etc.
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Who does the property belong to? Add details if known.
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Photographic evidence of damaged property
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Who does the property belong to?
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Add details of property stolen and value if known.
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Who does the property belong to?
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Add photograph of retrieved property,
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Add details of property retrieved and value if known.
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Where is the property? Returned to owner/passed to police/retained by security? (add details).
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Environmental- Large fuel spillage, Flood, Large gas leak etc.
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Enter Description.
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Was the centre closed/shut off/evacuated during trading hours, if Yes, add on whose authority?
Description of accident/incident.
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Full details of the Accident/Incident.
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Near Miss:
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Enter Details of Circumstances, include photographic evidence. Also add preventative measures/actions put in place to prevent this reoccurring.
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Management notified at time of near miss or as soon as practicable.
- SSC
- SSM
- Centre Manager
- Deputy Manager
- Ops Manager
- ROM
- Centre administrator
- Director
- No. N/A - Add reason
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Reason:
Additional information in relation to policies/processes.
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Potential Cause of Accident/Incident: Is there an obvious reason/cause:
- Yes
- No
- No Existing policy/procedure in place
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Add details:
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Add photos if applicable
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Breach of Existing Policies/Procedures:
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Add details:
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Do any of the following apply: <br>Lack of awareness<br>Skill<br>Training requirement<br>Miscommunication<br>Other
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State which are applicable and add actions/requirements to prevent any further issues/accidents/incidents.
- Lack of Awareness
- Skill
- Training
- Miscommunication
- Other
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Add details:
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Add any further information if required:
Officer completing this report: Sign and "Save". Forward to your Line manager who will review, sign and "Complete".
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Officer completing Report. I confirm that I have recorded this incident/accident/actions as accurately as possible providing all relevant and available information and evidence. Name and Signature
