INCIDENT INFORMATION

  • Type of incident

  • Name of injured person or person reporting

  • Date and time of incident

  • To whom was the incident reported?

  • Project, event or site

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

  • Photo of location

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

  • Witness 1

  • Witness 2

  • Witness 3

SECTION 1 - Personal Injury Details

  • Description of injury

  • Severity of injury

  • Detail any first-aid or medical treatment administered

  • Hospital treatment required

  • Hospital details

  • RIDDOR reportable

  • RIDDOR completed by

SECTION - 2 Injured Person Details

  • Name

  • Home address
  • Date of birth

  • Category

  • Employed by/Visiting/Guest of

SECTION 3 - Damage only or near miss

  • Nature of incident

  • Contractor or supplier involved

  • Members of the public involved

  • Photo of damage.

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

  • Likely cause

  • Contributing factors

  • Sketch (if appropriate)

  • Is urgent action required to make the area safe

  • If so, who by

  • Brief description of urgent remedial action

  • Photos of remedial action

  • RIDDOR reportable

  • RIDDOR completed by

SECTION 3 - Further analysis (if required)

  • Primary cause

  • Contributing (underlying) Factors:

  • Contributing factors photo:

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

  • What is the probability of reoccurrance?

Section 2 - Personal Injury Detail

SUPPORTING INFORMATION (if required)

  • Witness 1 statement

  • Print name

  • Witness 2 statement

  • Print name

  • Witness 3 statement

  • Print name

  • Additional photos

  • Sketch

  • Additional relevant information

Report Details

DOCUMENTATION CONTROL

  • Report completed by

  • Position

  • Print name

  • Select date

  • Copies to

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