Information

  • Report reference

  • OP No.

  • Client / Site

  • Conducted on

  • Prepared by

  • Location

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

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.