Title Page
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Site conducted
Incident Report Number
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DETAILS OF INCIDENT:
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Type of incident
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Date Of Incident
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Time in 24hr clock
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Was weather a contributing factor? If so state weather conditions
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MRI Code
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Site Address
- Crowngate Shopping centre, management suit, WR1 3LE
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Site client/ owner/ landlord name:
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Surveyor responsible
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Centre Manager/RFM
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Exact location of incident:
DETAILS OF AGGRIEVED OR INJURED PERSON(S):
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Name of person:
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Home address:
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Contact telephone number:
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Date of birth
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Age
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Status of person – please Select
- Member of the Public
- Employee
- Self Employed
- Tenant
- Contractor (By Tenant Or Savills Or Client)
- Retired
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Job title (if Savills or Contractor)
INJURY DETAILS:
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What type of injury has the person sustained? (Include body part injured)
- 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
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Did the person go direct to hospital from the scene?
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If yes By what means
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Was the person attended to by a first aider?
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What first aid was given?
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What was the name of the first aider?
WHAT HAPPENED?
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What Happened
Stage 1 Investigation
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Were there any witnesses? If so please provide details and statements with this form.
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Why Not
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How Many
- 0
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8
- 9
- 10
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Reference Number/s:
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Have photos been taken showing the location the Incident occurred?
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Why Not
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How Many
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Reference Number/s:
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Have photos been taken using something to demonstrate the scale or size of the issue?
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Why Not
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Have photos been taken showing the issue as being rectified or complete?
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Why Not
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How Many
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Reference Numbers
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Have all photos documented above been sent with this form?
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Why Not
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If you have altered/ enhanced photos, please detail the changes:
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Was the event caught on CCTV?
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Why Not
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Have you caught on CCTV the areas before the event occurred?
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Why Not
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Please burn 2 copies of CCTV footage of the incident and allocate reference numbers
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How long was the spillage/trip or defect that caused the incident in place?
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Do you believe the incident occurred due to the action of a contractor?
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If yes, please provide details of contractor, and their insurance details:
SECURITY/ THEFT/ POLICE INCIDENT REPORT
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Name of Police Officer:
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Crime number:
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Provide names/ details of potential suspects/ additional people involved:
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Prepared by
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Job Title
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Date / Time
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Location
INVESTIGATION: Stage 2 (to be carried out by Property Manager)
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Select which applies
- Slip, trips,falls
- Fall From Hight
- Verbal Abuse
- Physical Assault
- Injured By Lifting
- Pollution
- Other
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For other types please describe
For pollution incidents please use HSF43 must be completed along side this report
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For slip or trips please describe the person’s footwear:
- Stilettos
- Sandals
- Flip Flops
- Crocks
- Flat Shoes
- Medium held shoe
- Platforms
- Trainers
- Pumps
- Boots
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Have you reviewed your sites security patrol log? Please forward with this form.
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Why Not
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Have you reviewed your site specific security patrols procedure in light of the incident?
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When was the last patrol in the area? (24hr clock)
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How frequent are the patrols in that area?
- 1hr
- 2hr
- 3hr
- 4hr
- 5hr
- 6hr
- over 12 hrs
- over24 hrs
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Have you reviewed your sites cleaning patrol log? Please forward with this form.
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Why Not
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When was the last patrol in the area? (24hr clock)
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How frequent are the patrols in that area?
- 1hr
- 2hr
- 3hr
- 4hr
- 5hr
- 6hr
- over 12 hrs
- over24 hrs
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Have you reviewed your site specific cleaning patrols procedure in light of the incident?
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Why Not
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Have you made any amendments? If yes please detail
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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
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Why Not
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Which procedure/s do you have linked to the incident? Please detail:
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Have you reviewed your Site Specific Procedure documented above in light on the incident
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Why Not
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Have you made any amendments? If yes please detail
Check List Investigation
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Was the Daily Checklist carried on the day of the incident? Please forward with this form
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Why Not
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Have you reviewed the relevant weekly or monthly checklists? Please forward with this form.
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Why Not
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Was anything identified on the relevant checklist which could have contributed to the incident? Please note:
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Have you reviewed the relevant site defect repairs log? Please forward with this form
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Why Not
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How many defect repairs in that location have been completed reducing the risk of the incident? Please note:
Accident Analysis
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On the day in question what was the footfall for the property?
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For the week in question what was the footfall for the property?
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For the month in question what was the footfall for the property?
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On the day in question, was the footfall in line with normal expectation?
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For the week in question, was the footfall for the property in line with normal expectation?
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For the last two years what was the footfall for the property?
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In the last Month how many similar incidents have you had in that location?
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In the last twelve months how many similar incidents have you had in that location?
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Do you record your incidents on a monthly property Hot Spot Map?
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Have these Hot Spot Maps been forwarded with this form?
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Do You carry out Tool Box Talks?
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What Tool box talks relating to the incident have been carried out? and When?
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For manned properties, do you carry out a Monthly on Site H&S Meeting?
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Has the above incident analysis been discussed and recorded in the Properties monthly H&S Meeting?
RIDDOR / CLAIMS
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Is the incident RIDDOR Reportable?
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Do you think this incident may result in a claim:
Is there any other supporting documentation you would like to provide as part of this investigation?
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If Yes Provide details
COMPLETING THIS INVESTIGATION:
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Name of person completing form:
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Contact telephone number
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Today’s date:
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Date you became aware of the incident:
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Name
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Job Title
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Date