Minor Accident and Incident report form

• Date report completed.

  Date

• Date of incident

  Date

• Prepared by

• Employer

• Contractor involved if not the same as above

• Site Manager or person in charge

• Site Location
  Address

• Exact location of accident/incident

• Brief details of incident (When, Where, Who & Why) no more than 6 lines

  Provide details

• Number of injured persons?

  Provide details

• Number of witnesses?

  Provide details

• Fatality?

  Yes

  No

• Major Injury?

  Yes

  No

• Dangerous Occurrence?

  Yes

  No

• Minor injury exceeding 7 days away from work (RIDDOR Reportable)?

  Yes

  No

• Minor injury not exceeding 7 days but over 3 days away from work?

  Yes

  No

• Minor injury with no days away from work?

  Yes

  No

• Incident involving a member of the public

  Yes

  No

• Damage to organisations property / equipment

  Yes

  No

• Service strike

  Yes

  No

• Environmental Incident?

  Yes

  No

• Near Miss?

  Yes

  No

• Person 1

  Provide details

• Name:

• Address:

• Age: (D.O.B.)

• Contact number:

• Induction number (if issued):

• Date of induction:

• Trade / occupation:

• Employment status ( direct - Subcontractor - self-employed etc.)

• Injury(s) sustained (provide as much detail as possible):

• Hospital attended (or other i.e. doctor - medical centre)

• Likelihood of returning to work (when?)

• Employer / Agency / Self-Employed (insert details)

• Is this person ?

  Provide details

• The injured party?

  Yes

  No

• Witnessed the incident?

  Yes

  No

• Witnessed events before and/or after?

  Yes

  No

• Management on site?

  Yes

  No

• Other?

  Yes

  No

• Include events described by witness / injured party

  Provide details

Person 2 details

• Is there a second person involved? if so add the following details.

  Yes

  No

  N/A

• Name:

• Address:

• Age: (D.O.B.)

• Contact Number:

• Induction number (if issued)

• Date of induction:

• Trade / Occupation:

• Employment status ( direct - Subcontractor - self-employed etc.)

• Injury(s) sustained (provide as much detail as possible):

• Hospital attended (or other i.e. doctor - medical centre)

• Employer / Agency / Self-Employed (insert details)

• Is this person?

  Provide details

• Witnessed the incident?

  Yes

  No

• Witnessed events before and/or after?

  Yes

  No

• Management on site?

  Yes

  No

• Other?

  Yes

  No

• Include events described by witness / injured party

  Provide details

Person 3

• Is there a third person involved? if so add following details

  Yes

  No

  N/A

• Name:

  Yes

  No

  N/A

• Address:

  Yes

  No

  N/A

• Age: (D.O.B.)

  Yes

  No

  N/A

• Contact number?

  Yes

  No

  N/A

• Induction number (if issued)

  Yes

  No

  N/A

• Date of induction:

  Yes

  No

  N/A

• Trade / Occupation:

  Yes

  No

  N/A

• Employment status ( direct - Subcontractor - self-employed etc.)

  Yes

  No

  N/A

• Injury(s) sustained (provide as much detail as possible):

  Yes

  No

  N/A

• Hospital attended (or other i.e. doctor - medical centre)

  Yes

  No

  N/A

• Employer / Agency / Self-Employed (insert details)

  Yes

  No

  N/A

• Is this person?

  Provide details

• The injured party?

  Yes

  No

• Witnessed the incident?

  Yes

  No

• Witnessed events before and/or after?

  Yes

  No

• Management on site?

  Yes

  No

• Other?

  Yes

  No

• Include events described by witness / injured party

  Provide details

• Was any plant or equipment involved with the incident?

  Yes

  No

• Type of plant / equipment

• Owner of plant / equipment (hire company or direct)

• Owners contact details

• Registration number / serial number (or other identification)

• If hired, by whom?

• Operator (driver/user)?

• Details of operators cert of competence.

Plant / equipment (item2)

• Type of plant / equipment

• Owner of plant / equipment (hire company or direct)

• Owners contact details

• Registration number / serial number (or other identification)

• If hired, by whom?

• Operator details (driver/user)?

• Details of operators cert of competence

Plant / equipment (item 3)

• Type of plant / equipment

• Owner of plant / equipment (hire company or direct)

• Owners contact details

• Registration number / serial number (or other identification)

• If hire, by whom?

• Operator details (driver/user)

• Details of operators cert of competence

• Provide a summery of what happened and why,<br>

  Provide details

• Investigator - Comments / observations / recommendations Immediate steps taken to prevent a re-occurrence.<br>

  Provide details

• Please sign to confirm the information provided is an accurate account of what happened.

• Person completing report

  Sign

• Injured Person

  Sign

• Witness

  Sign