Title Page
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Site conducted
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Client name
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Prepared by
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Conducted on
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Location
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What time and date did the incident occur?
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Who was involved in the incident?
- Member of the public
- Direct Employee
- Sub Contractor
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What is the name of the person involved in the incident?
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Where in the work place did the incident occur?
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What was the condition of the workplace during the time of the incident
Injuries to a person
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Was anyone injured during the incident?
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If yes to above, please enter persons name, date of birth, home address and position within the company
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How was the person injured?
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Have their next of kin been informed?
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Was first aid administered to the injured person?
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Did the injured person require hospital admission?
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Is the incident reportable under RIDDOR?
The incident
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Provide a detailed description of the incident
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What is the primary underlying cause of the incident?
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What is the secondary underlying cause of the incident?
Actions / recommendations resulting from the incident
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Please detail what actions / recommendations have been carried out following the incident
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Signature of investigating person
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Date report completed
