Incident Report

• Location

• Conducted on

  Date

• Person involved

• Employee or Sub - contractor

  Employee

  Sub contractor

• Sub Contractor

• Category 1 - No injury / no external assistance / <£500
  Category 2 - Medical treatment / material loss <£1000
  Category 3 - Lost time injury / Hospital consultation / <£10,000
  Category 4 - Life threatening / fatal / Major loss >£10,000

• Classification

  Select Fatality RIDDOR Lost Time Injury Injury Property Damage Near Miss / Dangerous Occurence Environmental Incident

  • Fatality
  • RIDDOR
  • Lost Time Injury
  • Injury
  • Property Damage
  • Near Miss / Dangerous Occurence
  • Environmental Incident

• Category (Level) <br><br>

  Category 1

  Category 2

  Category 3

  Category 4

• Prepared by

• Document No.

Details

• Please provide a brief account of what happened

• Please provide details of any injuries sustained

• Photograph of injury (1)

  Media

• Photograph of injury (2)

  Media

• Was medical treatment required?

  Select No First Aid Hospital (day case) Hospital (overnight)

  • No
  • First Aid
  • Hospital (day case)
  • Hospital (overnight)

• Provide Hospital details & address

• Please provide details of any property damage

• Photograph of damage (1)

  Media

• Photograph of damage (2)

  Media

• Witness name (if any)

• Contact number

• Immediate post incident actions

• Details of actions to make situation safe?

• Details of immediate actions to prevent reoccurrence

Identifying causes of incidents

• Is a copy of Risk Assessment present and in place?

  Yes

  No

• Was relevant and appropriate PPE being worn?

  Yes

  No

• What was the sequence of events leading up to the incident?

• What unsafe actions may have contributed to incident? (Unsafe working, poor ladder set up etc)

• What unsafe conditions may have contributed to incident? (Uneven flooring, weather etc)

• Any additional factors that may have contributed to the incident

• Has the area been left in a safe condition?

  Select Yes No

  • Yes
  • No

• Please give details

• Photograph of area

  Media

Sign off

• Please ensure all details are correct to the best of your knowledge and information. Please send in to H&S@sccialphatrack.co.uk

• Person involved

  Sign

• Person completing report

  Sign