Injury, Accident, Incident Report

• Report reference

• OP No.

• Client / Site

• Conducted on

  Date

• Prepared by

• Location
  Address

INCIDENT INFORMATION

• Type of incident

  Select Minor Injury Major Injury Fatality Structural Failure Near Miss Road Traffic Incident Environmental

  • Minor Injury
  • Major Injury
  • Fatality
  • Structural Failure
  • Near Miss
  • Road Traffic Incident
  • Environmental

• Name of injured person or person reporting

• Date and time of incident

  Date

• To whom was the incident reported?

• Project, event or site

• Exact location on site (include grid ref if available)

• Photo of location

  Media

• Were there any witness(es)? If yes, provide name(s).

  Yes

  No

  N/A

• Witness 1

• Witness 2

• Witness 3

SECTION 1 - Personal Injury Details

• Description of injury

• Severity of injury

  Select Minor Injury (no formal treatment required) Minor Injury (on-site first aid) Referred to Hospital 999 Ambulance Fatality

  • Minor Injury (no formal treatment required)
  • Minor Injury (on-site first aid)
  • Referred to Hospital
  • 999 Ambulance
  • Fatality

• Detail any first-aid or medical treatment administered

• Hospital treatment required

  Yes

  No

  N/A

• Hospital details

• RIDDOR reportable

  Yes

  No

  N/A

• RIDDOR completed by

  Select Site Safety Team Contractor Venue Other (give details)

  • Site Safety Team
  • Contractor
  • Venue
  • Other (give details)

SECTION - 2 Injured Person Details

• Name

• Home address
  Address

• Date of birth

  Date

• Category

  Select Event employee Contractor Freelance worker Venue staff Visitor Member of the public Other Employee

  • Event employee
  • Contractor
  • Freelance worker
  • Venue staff
  • Visitor
  • Member of the public
  • Other Employee

• Employed by/Visiting/Guest of

SECTION 3 - Damage only or near miss

• Nature of incident

  Select Structural Collapse Trip Hazard Road Traffic Collision Electrical Fairground Food & Bev Spillage Special Effects Chemical Plant

  • Structural Collapse
  • Trip Hazard
  • Road Traffic Collision
  • Electrical
  • Fairground
  • Food & Bev
  • Spillage
  • Special Effects
  • Chemical
  • Plant

• Contractor or supplier involved

• Members of the public involved

  Yes

  No

  N/A

• Photo of damage.

  Media

• Detailed description of incident. (Include environmental conditions at time of incident)

• Likely cause

• Contributing factors

• Sketch (if appropriate)

  Drawing

• Is urgent action required to make the area safe

  Yes

  No

  N/A

• If so, who by

• Brief description of urgent remedial action

• Photos of remedial action

  Media

• RIDDOR reportable

  Yes

  No

  N/A

• RIDDOR completed by

  Select Site Safety Team Contractor Venue Other (give details)

  • Site Safety Team
  • Contractor
  • Venue
  • Other (give details)

SECTION 3 - Further analysis (if required)

• Primary cause

• Contributing (underlying) Factors:

• Contributing factors photo:

  Media

• Corrective Action (Include detail description of action and person(s) responsible for actions)

• What is the probability of reoccurrance?

  Select Highly Unlikely Unlikely Possible Probable Highly Probable Certainty

  • Highly Unlikely
  • Unlikely
  • Possible
  • Probable
  • Highly Probable
  • Certainty

SUPPORTING INFORMATION (if required)

• Witness 1 statement

• Print name

  Sign

• Witness 2 statement

• Print name

  Sign

• Witness 3 statement

• Print name

  Sign

• Additional photos

  Media

• Sketch

  Drawing

• Additional relevant information

DOCUMENTATION CONTROL

• Report completed by

• Position

• Print name

  Sign

• Select date

  Date

• Copies to

  Select injured person contractor promoter/client local authority HSE police

  • injured person
  • contractor
  • promoter/client
  • local authority
  • HSE
  • police