Title Page
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Site conducted
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Conducted on
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Prepared by
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Location
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Incident Type
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Who owns the property?
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Have they been informed?
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Are vehicles involved?
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Type of vehicle(s)
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Vehicle Registration or Identification Number
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Do You Want To Add Photos?
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Date of Incident
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Site Location (where did the incident take place?)
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Are the details of the person involved in the incident known?
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Name Of Person Involved In Incident
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Address
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DOB
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Contact Number
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Are they
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Role
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Employer
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Hours Of Work?
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Did they complete a Health & Safety Induction?
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Details
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Details
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Are there any injuries?
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Details of any injuries
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Did the person require medical attention?
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Treated by
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Were they advised to attend hospital?
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Did they attend hospital
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If person does not seek further medical attention if advised to do so they must sign here that they understand the advice given by the medical team and the consequences of not seeking further medical attention.
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Signature of person involved in incident
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Did they return to work?
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Is a RIDDOR Report Required
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Were there any witnesses
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Witness Details
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Witness Contact Number
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Reported To
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Role
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Incident Type?
- PPE
- Vehicle
- Speeding
- Competency License
- Structural
- Overcrowding
- Slips/Trips/Falls
- Manual Handling
- Electrical
- Lighting
- Plumbing
- Permit Breach
- Unsafe Practice
- Working At Height
- Medical
- Noise
- Dust
- Fire Safety
- Means Of Escape
- Housekeeping
- Stress
- Harassment
- Violence/Assault
- Hygiene
- Food Safety
- Flooding
- Weather
- Other
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Incident Description (Describe what happened)
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Initial assessment of the cause of the incident?
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Corrective actions taken to prevent reoccurrence.
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Is A Risk Assessment Required?
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Signed
