TPT-1062 Rev - 'INCIDENT REPORT FORM'

• Complete form as fully as possible. On completion, choose 'Complete Inspection' and email PDF report to m.thomas@theparkstrust.com. If at Willen add Rob Wood or Duty Manager to email recipients.

1. About the Person who had the Accident

• Full Name:

• Category of person

  Select

• Job Title

• Address:

• Post Code:

• Age:

• Telephone Number

2. About the Person Completing this Form

• Full Name

• Job Title

• Date Form Completed

  Date

3.Type of Incident

• Select the incident type

  Select

4. About the Incident

• Date of Incident:

  Date

• Where did the Incident Happen?

• How did the Incident Happen / Cause (Give details of exactly what, how and why the incident happened):

• Were there any witnesses?

  Select

• Witness 1 Name

• Witness 1 Contact Number

5. About any Injuries & Treatment

• Details of Injury:

• Part of Body:

  Drawing

• Are the injuries serious (Life Threatening or Loss of Limb)?:

  Select

• Notify Line Manager or Willen General Manager Immediately (as applicable)

• Treatment Required:

  Select

• First Aider Name:

• Details of any First Aid / Treatment Given:

• If Taken to A&E, which hospital?:

6. Causes

• What are considered as contributory causes?

• Inadequate Training

• Insufficient Care taken by Employee

• Poor Housekeeping

• PPE

• Tools or Equipment

• Caused by 3rd Person

7. Signatures

• Signature of Person Completing Form

  Sign

• Date:

  Date

• Signature of Injured Person (or Parent / Guardian if Under 16):

  Sign

• Date:

  Date

• Name of Parent / Guardian - If Applicable (Print):