Incident Report Form HSF01

• Site conducted

  Select

Incident Report Number

• undefined

DETAILS OF INCIDENT:

• Type of incident

• Date Of Incident

  Date

• Time in 24hr clock

  Date

• Was weather a contributing factor? If so state weather conditions

  yes

  No

  N/a

• MRI Code

  5142

• Site Address

  Select Crowngate Shopping centre, management suit, WR1 3LE

  • Crowngate Shopping centre, management suit, WR1 3LE

• Site client/ owner/ landlord name:

• Surveyor responsible

• Centre Manager/RFM

• Exact location of incident:

DETAILS OF AGGRIEVED OR INJURED PERSON(S):

• Name of person:

• Home address:

• Contact telephone number:

• Date of birth

• Age

• Status of person – please Select

  Select Member of the Public Employee Self Employed Tenant Contractor (By Tenant Or Savills Or Client) Retired

  • Member of the Public
  • Employee
  • Self Employed
  • Tenant
  • Contractor (By Tenant Or Savills Or Client)
  • Retired

• Job title (if Savills or Contractor)

INJURY DETAILS:

• What type of injury has the person sustained? (Include body part injured)

  Select N/A Head Face Face Left Side Face Right side Nose Ear Left Ear Right Arm Left Arm Right Hand Left Hand Right Fingers Left Hand Fingers Right hand Chest Torso Stomach Back Upper Back Lower Left Hip Right Hip Buttocks Pelvis Groin Left Leg Right Leg Left Knee Right Knee Left Foot Right Foot

  • N/A
  • Head
  • Face
  • Face Left Side
  • Face Right side
  • Nose
  • Ear Left
  • Ear Right
  • Arm Left
  • Arm Right
  • Hand Left
  • Hand Right
  • Fingers Left Hand
  • Fingers Right hand
  • Chest
  • Torso
  • Stomach
  • Back Upper
  • Back Lower
  • Left Hip
  • Right Hip
  • Buttocks
  • Pelvis
  • Groin
  • Left Leg
  • Right Leg
  • Left Knee
  • Right Knee
  • Left Foot
  • Right Foot

• Did the person go direct to hospital from the scene?

  Yes

  No

  Not Required

• If yes By what means

  Ambulance

  Taxi

  Car

  Bus

  Police Car

• Was the person attended to by a first aider?

  yes

  No

  N/a

• What first aid was given?

• What was the name of the first aider?

WHAT HAPPENED?

• What Happened

Stage 1 Investigation

• Were there any witnesses? If so please provide details and statements with this form.

  Yes

  No

  Unsure

• Why Not

• How Many

  Select 0 1 2 3 4 5 6 7 8 9 10

  • 0
  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8
  • 9
  • 10

• Reference Number/s:

• Have photos been taken showing the location the Incident occurred?

  Yes

  No

  Unsure

• Why Not

• How Many

• Reference Number/s:

  As previous question

• Have photos been taken using something to demonstrate the scale or size of the issue?

  yes

  No

  N/a

• Why Not

• Have photos been taken showing the issue as being rectified or complete?

  yes

  No

  N/a

• Why Not

• How Many

• Reference Numbers

  As previous question

• Have all photos documented above been sent with this form?

  yes

  No

  N/a

• Why Not

• If you have altered/ enhanced photos, please detail the changes:

• Was the event caught on CCTV?

  yes

  No

  N/a

• Why Not

• Have you caught on CCTV the areas before the event occurred?

  yes

  No

  N/a

• Why Not

• Please burn 2 copies of CCTV footage of the incident and allocate reference numbers

• How long was the spillage/trip or defect that caused the incident in place?

• Do you believe the incident occurred due to the action of a contractor?

  Yes

  No

  Not Required

• If yes, please provide details of contractor, and their insurance details:

SECURITY/ THEFT/ POLICE INCIDENT REPORT

• Name of Police Officer:

• Crime number:

• Provide names/ details of potential suspects/ additional people involved:

• Prepared by

• Job Title

  Ops Manager

  GM

  Security supervisor

  Security officer

• Date / Time

  Date
• Location
  Address

INVESTIGATION: Stage 2 (to be carried out by Property Manager)

• Select which applies

  Select Slip, trips,falls Fall From Hight Verbal Abuse Physical Assault Injured By Lifting Pollution Other

  • Slip, trips,falls
  • Fall From Hight
  • Verbal Abuse
  • Physical Assault
  • Injured By Lifting
  • Pollution
  • Other

• For other types please describe

For pollution incidents please use HSF43 must be completed along side this report

• For slip or trips please describe the person’s footwear:

  Select Stilettos Sandals Flip Flops Crocks Flat Shoes Medium held shoe Platforms Trainers Pumps Boots

  • Stilettos
  • Sandals
  • Flip Flops
  • Crocks
  • Flat Shoes
  • Medium held shoe
  • Platforms
  • Trainers
  • Pumps
  • Boots

• Have you reviewed your sites security patrol log? Please forward with this form.

  yes

  No

  N/a

• Why Not

• Have you reviewed your site specific security patrols procedure in light of the incident?

  yes

  No

  N/a

• When was the last patrol in the area? (24hr clock)

  Date

• How frequent are the patrols in that area?

  Select 1hr 2hr 3hr 4hr 5hr 6hr over 12 hrs over24 hrs

  • 1hr
  • 2hr
  • 3hr
  • 4hr
  • 5hr
  • 6hr
  • over 12 hrs
  • over24 hrs

• Have you reviewed your sites cleaning patrol log? Please forward with this form.

  yes

  No

  N/a

• Why Not

• When was the last patrol in the area? (24hr clock)

  Date

• How frequent are the patrols in that area?

  Select 1hr 2hr 3hr 4hr 5hr 6hr over 12 hrs over24 hrs

  • 1hr
  • 2hr
  • 3hr
  • 4hr
  • 5hr
  • 6hr
  • over 12 hrs
  • over24 hrs

• Have you reviewed your site specific cleaning patrols procedure in light of the incident?

  yes

  No

  N/a

• Why Not

• Have you made any amendments? If yes please detail

  Yes

  No

  Not Required

• Do you have a Site Specific Procedure for the incident in question? Example may be Slips, Trips and Falls procedure, or Defect Control, or Gritting? Please forward with this form

  Yes

  No

  Unsure

• Why Not

• Which procedure/s do you have linked to the incident? Please detail:

• Have you reviewed your Site Specific Procedure documented above in light on the incident

  Yes

  No

  Unsure

• Why Not

• Have you made any amendments? If yes please detail

  Yes

  No

  Not Required

Check List Investigation

• Was the Daily Checklist carried on the day of the incident? Please forward with this form

  yes

  No

  N/a

• Why Not

• Have you reviewed the relevant weekly or monthly checklists? Please forward with this form.

  yes

  No

  N/a

• Why Not

• Was anything identified on the relevant checklist which could have contributed to the incident? Please note:

• Have you reviewed the relevant site defect repairs log? Please forward with this form

  yes

  No

  N/a

• Why Not

• How many defect repairs in that location have been completed reducing the risk of the incident? Please note:

Accident Analysis

• On the day in question what was the footfall for the property?

• For the week in question what was the footfall for the property?

• For the month in question what was the footfall for the property?

• On the day in question, was the footfall in line with normal expectation?

  Yes

  No

  Unsure

• For the week in question, was the footfall for the property in line with normal expectation?

  Yes

  No

  Unsure

• For the last two years what was the footfall for the property?

• In the last Month how many similar incidents have you had in that location?

• In the last twelve months how many similar incidents have you had in that location?

• Do you record your incidents on a monthly property Hot Spot Map?

  yes

  No

  N/a

• Have these Hot Spot Maps been forwarded with this form?

  Yes

  No

  Unsure

• Do You carry out Tool Box Talks?

  Yes

  No

  Unsure

• What Tool box talks relating to the incident have been carried out? and When?

• For manned properties, do you carry out a Monthly on Site H&S Meeting?

• Has the above incident analysis been discussed and recorded in the Properties monthly H&S Meeting?

  Yes

  No

  Unsure

RIDDOR / CLAIMS

• Is the incident RIDDOR Reportable?

  Yes

  No

  Not Required

• Do you think this incident may result in a claim:

  Yes

  No

  Unsure

Is there any other supporting documentation you would like to provide as part of this investigation?

• If Yes Provide details

COMPLETING THIS INVESTIGATION:

• Name of person completing form:

• Contact telephone number

• Today’s date:

  Date

• Date you became aware of the incident:

  Date

• Name

• Job Title

  Ops Manager

  GM

  Security supervisor

  Security officer

• Date

  Date

Send form to incidents@savill.com within 3 day of the incident

If the incident is reportable, inform the H&S team will repiort all notifiable incidents under RIDDOR