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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Not sure? - Help Attached!
Details of person who had the accident
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Name of the person who had the accident
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Occupation of the person who had the accident
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Employed or Agency Worker
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Not sure? - Help Attached!
Details of person taking this report
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Name of the person filling out this report
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Occupation of the person taking this report
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Not sure? - Help Attached!
Details of the accident - when and where
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Date and time of the accident
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Location of Accident?
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Did Police/Ambulance/HSE attend location?
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Which Emergency service attended?
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Has the injured party returned to work
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Please complete date of return to work
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Not sure? - Help Attached!
About the accident
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Explain what happened, also describe the injury if any and if known the cause of the accident
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Category of Incident
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Was first aid given
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What first aid was given and what materials where used?
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Not sure? - Help Attached!
For the employer only to complete this section
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Was the injury Fatal?
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Was the injury a Major Injury? (Due to Ambulance or Emergency Services Attending)
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Which Service Attended?
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Was the injury an over 7 day injury?
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Has a RIDDOR been completed and Submitted
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Was the injury an over 3 day non reportable injury?
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None of these and not reportable
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Have Risk Assessments been reviewed
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Have these been updated or changed?
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Have the SSOW been updated
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Have these been reissued to all relevant staff, and signatures of understanding recorded?
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Has the Accident information been entered onto the KPI Personal Health & Safety detail sheet or Vehicle accident sheet if required on the day of the Incident.
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Have this accident been reported to the site management?
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Not sure? - Help Attached!
Signatures
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Signature of person making the report
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Signature of the person who had the accident
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Not sure? - Help Attached!
