Title Page
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Job Number
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Site Address
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Client
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Conducted on
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Prepared by
IP details
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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.
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Name of injured party (IP)
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Enter IP statement of events.
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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.
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Is the IP English?
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Did you use a translator when taking the statement?
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Enter the translators name.
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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.
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Translator to sign to say they have relayed the correct information.
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Have you taken an audio recording whilst taking their statement?
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Please make sure you send a copy of the recording when notifying the H&S team.
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Why have you not taken a recording?
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Did IP sign their statement?
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Enter why the IP could not sign their statement
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In the case of the IP needing to get further assistance from a medical facility, was a statement taken before leaving site?
Incident Details
Type of Incident
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Date and time of incident
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Are you being made aware of this injury on the day it happened ?
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What type of injury was sustained?
- Minor injury (not otherwise listed)
- Specified injuries to workers
- Over-seven-day incapacitation of a worker
- Non fatal accidents to non-workers (eg. members of the public)
- Occupational diseases
- Dangerous occurrences
- Gas incidents
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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?
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Describe injury including location on the body, size and appearance.
- Minor injury (not otherwise listed)
- Specified injuries to workers
- Over-seven-day incapacitation of a worker
- Non fatal accidents to non-workers (eg. members of the public)
- Occupational diseases
- Dangerous occurrences
- Gas incidents
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Add a picture of the injury
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Did the IP go to Hospital from site?
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Did the IP seek medical advice at some other point?
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If Yes enter details as to when and by whom?
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Add a picture of supporting medical documents
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Have you been shown evidence of supporting medical evidence
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Add a picture.
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Why Not?
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Enter details leading up to the event
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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.
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Take photo of surrounding environment
Making the area safe
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What actions were taken to make the area safe?
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Add pictures to show area has been made safe.
Witness recording
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Was there any witnesses to the event?
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Enter the name of the first witness
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Add their account of what happened
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Add signature of witness to confirm their account is true to the best of their knowledge.
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Was there any other witnesses to the event?
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Enter the name of the subsequent witness
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Enter their account of what happened
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Add signature of witness to confirm their account is true to the best of their knowledge.
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Was there any other witnesses to the event?
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Enter the name of the subsequent witness
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Enter their account of what happened
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Add signature of witness to confirm their account is true to the best of their knowledge.
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Was there any other witnesses to the event?
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Enter the name of the subsequent witness
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Enter their account of what happened
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Add signature of witness to confirm their account is true to the best of their knowledge.
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Was there any other witnesses to the event?
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Enter the name of the subsequent witness
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Enter their account of what happened
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Add signature of witness to confirm their account is true to the best of their knowledge.
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Was there any other witnesses to the event?
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Enter the name of the subsequent witness
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Enter their account of what happened
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Add signature of witness to confirm their account is true to the best of their knowledge.
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Enter the supervisor in charge of that area's statement as to what they were doing at the time of the incident
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Add signature of witness to confirm their account is true to the best of their knowledge.
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Add any photos you may find useful
Document Evidence Recording
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This section is only applicable when an injury has been sustained, IT MUST BE COMPLETED.
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Please take a picture of the signature sheet on the RAMS showing where the IP has signed once inducted.
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Please take a picture of the signature sheet on the Daily Briefings showing where the IP has signed once inducted.
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What evidence do you have that the IP was competent to undertake the work they were assigned to?
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Is it claimed the injury may have been caused by someone else?
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Add details of the person who its claimed to have been caused by.
Add details of any training certificates for the other person involved.
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Add a picture of above evidence.
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Do you have a copy of the IP's training certs on site?
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Have you seen evidence of the IP's training?
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Was there CCTV available?
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Please make sure you take a copy of the recording.
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What is the employment status of the IP?
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Please enter details of Other.
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How long has the IP been on site in days?
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Please enter the details of a tool box training given
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Please add a picture of signature page showing IP's signature.
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Has the IP had any other tool box talks?
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Please enter the details of the next tool box training given
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Please add a picture of signature page showing IP's signature.
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Has the IP had any other tool box talks?
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Please enter the details of the next tool box training given
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Please add a picture of signature page showing IP's signature.
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Has the IP had any other tool box talks?
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Please enter the details of the next tool box training given
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Please add a picture of signature page showing IP's signature.
Anything further to add
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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.
Sign off
Sign Off
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This must be completed by the Site Manager .
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Have you notified the Health & Safety department and the Op's manager for the project?
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You must send a copy of this report copying in the Op's manager and H&S department as soon as possible
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What Lessons have you learnt from this?
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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.
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Is this the first injury of this type on site?
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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.
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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
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Use this section to highlight where info was not available at the time of writing this report
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Detail what is outstanding
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When do you expect to get this information by?
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A back to work interview must be carried out for anybody that due to an injury leaves site before the end of their shift.
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Will you be expected to carry out a back to work interview?
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When is the IP expected to return to work?
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Signed off by site manager when corrective actions have been adopted and monitored
