IP details

When speaking with an operative where English is not their first language please make sure you record the witness statement using the audio recorder on your phone. You must tell them you are doing this prior to taking their statement. If they refuse to be recorded please mention this in the report.

Name of injured party (IP)

How long as the IP been working on site?

What level of training has the IP received?

Enter details of CSCS /CCDO card or trade equivalent.

How experienced is the IP?

Enter details of task related experience, how long they have been working in the industry and previous employment history.

What work status is the IP?

Add details of Agency

How long have they worked for KpH?

Enter details

Enter IP statement of events.

Please ask IP to sign and inform them by signing this statement they accept is is a true account of the events to the best of their knowledge.

Is the IP English?

Did you use a translator when taking the statement?

Enter the translators name.

The translator must be asked to translate your questions only and ask them to answer exactly what the operative has told them. Please ask them to sign below to say they understand this and have answered truthfully what they have been told to the best of their knowledge.

Translator to sign to say they have relayed the correct information.

Have you taken an audio recording whilst taking their statement?

Please make sure you send a copy of the recording when notifying the H&S team.

Why have you not taken a recording?

Was the IP able to sign their witness statement?

Enter why the IP could not sign their statement

In the case of the IP needing to get further assistance from a medical facility, was a statement taken before leaving site?

First Aid

What first aid was administered?

Who administered the first aid?

Where was the first aid administered?

What time was the first aid administered?

Did the IP require further treatment from a Medical facility?

Did the IP leave the site immediately to go to hospital?

When will the IP get further assessment?

Is the IP fit to resume normal work?

What was done at the hospital?

Did the IP return to work after visiting the hospital?

Was the IP given any medication to take at home?

Will the medication effect the IP to carry out their work safely?

Is there any restrictions imposed on the IP by the hospital?

Is the IP fit to resume normal work?

When will the IP be able to resume normal work?

Over-seven-day incapacitation of a worker: Accidents must be reported (RIDDOR) where they result in an employee or self-employed person being away from work, or unable to perform their normal work duties, for more than seven consecutive days as the result of their injury. This seven day period does not include the day of the accident, but does include weekends and rest days. The report must be made within 15 days of the accident.

Incident Details

Type of Incident
Date and time of incident

Are you being made aware of this injury on the day it happened ?

What type of injury was sustained?

RIDDOR is the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013. You must report:

Workplace deaths (excluding suicide).
Injuries that result in an employee being off work (or unable to complete their normal work duties) for seven consecutive days.
Incidents involving members of the public being injured and taken to hospital.
RIDDOR also covers certain workplace incidents. This includes specific injuries, occupational diseases, dangerous occurrences, and gas incidents.

Is this injury a RIDDOR?

Describe injury including location on the body, size and appearance.

Add a picture of the injury
What PPE Was the IP wearing?

Enter details.

Add a picture of the PPE if applicable to the injury

Enter details leading up to the event

When entering details mention things like: The time the shift started. What if any briefings they had that shift. How long the IP had been carrying out the task. If the IP was working in pairs how long they had worked together. What was it they were supposed to be doing.

Take photo of surrounding environment

Details of documentation

Was a daily briefing given?

At what time?

Was the IP made aware of their task for the day?

Did the injury occur whilst carrying out the task the IP was assigned to do?

Did the RAMS highlight the hazard? Add details

Were the controls in the RAMS appropriate for the hazard that caused the injury? Add details

Were the RAMS followed?

Did the injury occur because the IP was carrying out an activity they were not assigned to do?

Was the activity that lead to the injury identified within the RAMS? Add details

Were the controls in the RAMS appropriate for the hazard that caused the injury? Add details

Were the RAMS followed? Add details

Add details

Had the IP been inducted to the Safe System Of Works (RAMS) for the project and signed to say they understood the activities on site and the controls in place?

When was the IP inducted on site?

Supervision

Where was the site manager at the time of the incident?

Where was the floor supervisor/s at the time of the incident?

When was the last time the IP had been seen working safely?

Making the area safe

What actions were taken to make the area safe?

Add pictures to show area has been made safe.

Witness recording

Was there any witnesses to the event?

Enter the name of the first witness

Add their account of what happened

Add signature of witness to confirm their account is true to the best of their knowledge.

Was there any other witnesses to the event?

Enter the name of the subsequent witness

Enter their account of what happened

Add signature of witness to confirm their account is true to the best of their knowledge.

Was there any other witnesses to the event?

Enter the name of the subsequent witness

Enter their account of what happened

Add signature of witness to confirm their account is true to the best of their knowledge.

Was there any other witnesses to the event?

Enter the name of the subsequent witness

Enter their account of what happened

Add signature of witness to confirm their account is true to the best of their knowledge.

Was there any other witnesses to the event?

Enter the name of the subsequent witness

Enter their account of what happened

Add signature of witness to confirm their account is true to the best of their knowledge.

Was there any other witnesses to the event?

Enter the name of the subsequent witness

Enter their account of what happened

Add signature of witness to confirm their account is true to the best of their knowledge.
Add signature of witness to confirm their account is true to the best of their knowledge.
Add any photos you may find useful

Document Evidence Recording

This section is only applicable when an injury has been sustained, IT MUST BE COMPLETED.

Please take a picture of the signature sheet on the RAMS showing where the IP has signed once inducted.
Please take a picture of the signature sheet on the Daily Briefings showing where the IP has signed once inducted.
What evidence do you have that the IP was competent to undertake the work they were assigned to?

Is it claimed the injury may have been caused by someone else?

Add details of the person who its claimed to have been caused by.

Add details of any training certificates for the other person involved.
Add a picture of above evidence.

Do you have a copy of the IP's training certs on site?

Have you seen evidence of the IP's training?

Was there CCTV available?

Please make sure you take a copy of the recording.

How long has the IP been on site in days?

Please enter the details of a tool box training given

Please add a picture of signature page showing IP's signature.

Has the IP had any other tool box talks?

Please enter the details of the next tool box training given

Please add a picture of signature page showing IP's signature.

Has the IP had any other tool box talks?

Please enter the details of the next tool box training given

Please add a picture of signature page showing IP's signature.

Has the IP had any other tool box talks?

Please enter the details of the next tool box training given

Please add a picture of signature page showing IP's signature.

What tool box talks has the Operative been given?

Add a picture

Anything further to add

Please use this section if you would like to add any other information related to the incident that is not mentioned elsewhere in the report.

Completion

Sign Off

This must be completed by the Site Manager .

Have you notified the Health & Safety department and the Op's manager for the project?

You must send a copy of this report copying in the Op's manager and H&S department as soon as possible

What Lessons have you learnt from this?

A lessons learnt is something that can be taken and passed onto all other sites when carrying out the same activity to prevent reoccurring events. A lesson learnt can be "When working with glass, due to how hard it is to grip, consider the use of glass suction pads....etc.

Is this the first injury of this type on site?

If you have more then one injury of this type, even where it is considered a minor injury YOU MUST look into the causes. Consider involving the entire team and carry out an on site assessment of the process. Maybe the RA has changed or is not adequate enough and requires different controls in place? Perhaps the site or specific team needs to have a further bespoke safety consultation to discuss the amount or reoccurring incidents. DO NOT ALLOW IT TO CONTINUE WITHOUT DOING SOMETHING. Speak with your Health & Safety Department to ask for further advice if you have carried out the above already.

Enter the Site managers comments as to what they have put in place (corrective actions) to prevent this from happening again.

Follow up information required

Use this section to highlight where info was not available at the time of writing this report

Detail what is outstanding

When do you expect to get this information by?

A back to work interview must be carried out for anybody that due to an injury leaves site before the end of their shift.

Will you be expected to carry out a back to work interview?

When is the IP expected to return to work?
Signed off by site manager when corrective actions have been adopted and monitored
Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.