Incident Report Form

• Incident Report Form

Section 1 - Incident Report (to be completed at the time of the incident)

• Please indicate what type of incident you are reporting:

  Injury Incident

  Ill Health Incident

  Property Damage Incident

  Near Miss

  Dangerous Occurrence

Incident Details

• In which facility/site/area did the incident take place?

  Select Magnum Leisure Centre Auchenharvie Leisure Centre Vikingar Garnock Swimming Pool KA Campus Golf Outdoor Sports Facilities Health & Fitness Activities Sports Development Activities

  • Magnum Leisure Centre
  • Auchenharvie Leisure Centre
  • Vikingar
  • Garnock Swimming Pool
  • KA Campus
  • Golf
  • Outdoor Sports Facilities
  • Health & Fitness Activities
  • Sports Development Activities

• Which KA Campus?

  Select Arran Dalry Greenwood Kilwinning St. Matthews West Kilbride Stanley Primary

  • Arran
  • Dalry
  • Greenwood
  • Kilwinning
  • St. Matthews
  • West Kilbride
  • Stanley Primary

• Which Golf Course?

  Select Auchenharvie GC Ravenspark GC Routenburn GC

  • Auchenharvie GC
  • Ravenspark GC
  • Routenburn GC

• Which Outdoor Sports Facility?

• At which site did the incident occur within a Health & Fitness activity?

• At which site did the incident occur within a Sports Development activity?

• Where within the site/facility did the incident take place?

• Date and Time of the Incident

  Date

Injured Person (if applicable)

• Full Name

• Home Address and Postcode
  Address

• Telephone Number

• Age

• Sex:

  Male

  Female

Status of Injured Person

• Is the injured person:

  Member of the Public

  Contractor

  Visitor

  KA Leisure Employee

• Job Title

• Employee Number

• What is the name of the contractor's employer?

Full Description of Incident

• Please provide as much information as possible:

Witness Details

• Were there any witnesses of the incident?

  Yes

  No

  N/A

• Witness Name

• Contact Number

• Address and Postcode
  Address

• Is the witness a KA Leisure Employee?

  Yes

  No

  N/A

• Were there any other witnesses?

  Yes

  No

  N/A

• Witness Name

• Contact Number

• Address and Postcode
  Address

• Is the witness a KA Leisure employee?

  Yes

  No

  N/A

First Aid Treatment

• What treatment was administered?

• Name of First Aider:

• Was the Injured Person advised to attend A&E?

  Yes

  No

  N/A

• Did the injured person:

  Become unconscious

  Need resuscitation

  N/A

• For how long was the injured person unconscious?

Injury Details

• Nature of Injury (i.e. fracture, burn, cut etc.)

• Part of body affected (i.e. head, arm, leg etc.):

• Kind of Accident

  Select Trip/Slip or fall on same level Fall from height Drowned or next drowning Hit by something fixed or stationary Hit by something moving or a falling object Cuts from sharp objects Sports activity injury Injured while lifting, moving or carrying Exposure to fire or explosion Exposed to or in contact with a harmful substance Contact with electricity Contact with moving machinery Trapped by collapsing object or materials Physically assaulted by person Hit by moving vehicle Road traffic accident Other (Please Detail)

  • Trip/Slip or fall on same level
  • Fall from height
  • Drowned or next drowning
  • Hit by something fixed or stationary
  • Hit by something moving or a falling object
  • Cuts from sharp objects
  • Sports activity injury
  • Injured while lifting, moving or carrying
  • Exposure to fire or explosion
  • Exposed to or in contact with a harmful substance
  • Contact with electricity
  • Contact with moving machinery
  • Trapped by collapsing object or materials
  • Physically assaulted by person
  • Hit by moving vehicle
  • Road traffic accident
  • Other (Please Detail)

• More detail:

Form Completed By:

• Add signature

  Sign

• Occupation

• Home Address
  Address

Section 2 - Accident Investigation (to be completed by responsible manager)

• Is the incident reportable under RIDDOR?

  Yes

  No

  N/A

• Select Fatality Major Injury Over 7 day incapacitation (staff) Injury to member of the public which meant they had to be taken from the scene of the accident directly to hospital by ambulance

  • Fatality
  • Major Injury
  • Over 7 day incapacitation (staff)
  • Injury to member of the public which meant they had to be taken from the scene of the accident directly to hospital by ambulance

• Select Minor Injury No Injury Not work related

  • Minor Injury
  • No Injury
  • Not work related

• Reason why N/A?

Accident Investigation

• Type of Incident

  Fatality or serious injury. RIDDOR reportable.

  Dangerous occurrence or near miss where serious injury or damage could have occurred.

  RIDDOR reportable work related 7 day and over incident - minor injury to member of staff

  Minor injury or near miss where hazards have been identified

  Other

• Responsible manager (preliminary report). H&S Co-ordinator and Leisure Manager (investigation).

  Yes

  No

  N/A

• Responsible manager (preliminary report). H&S Co-ordinator and Leisure Manager (investigation).

  Yes

  No

  N/A

• Responsible Manager.

  Yes

  No

  N/A

• Responsible Manager.

  Yes

  No

  N/A

Managers Report

• Check the scene, detail any hazards identified which may have contributed to the incident, speak to the first aider and any witnesses where possible. Detail any remedial action taken/required.

Completed By

• Add signature

  Sign

• Designation

• Date

  Date

Health & Safety Co-ordinator Report

• Date Received

  Date

• RIDDOR reportable

  Yes

  No

  N/A

• Further investigation required

  Yes

  No

  N/A

• Add signature

  Sign