Near Miss and AAW Investigation

• Conducted on

  Date

• Prepared by

• Location
  Address

PLEASE COMPLETE ALL FIELDS FULLY AND ACCURATELY

• Type of incident

  Select Work-related Injury Work Related Injury - Home Service & Supply Road Traffic Accident Near Miss Physical Abuse or Threat Service Damage -Home Service & Supply Hazard Observation Work-related Illness/Condition Medical Issue (NOT related to work) Fire Incident Enforcement Action

  • Work-related Injury
  • Work Related Injury - Home Service & Supply
  • Road Traffic Accident
  • Near Miss
  • Physical Abuse or Threat
  • Service Damage -Home Service & Supply
  • Hazard Observation
  • Work-related Illness/Condition
  • Medical Issue (NOT related to work)
  • Fire Incident
  • Enforcement Action

• Is this incident likely to lead to an over 7 day absence?

  Yes

  No

• Time and Date of Incident

  Date
• Where did this happen?
  Address

Details of Affected Person

• Were there people injured/affected or involved in this Incident?

  Yes

  No

• Name/Tech Number

• Category of Person

  Select Employee (Permanent) Employee (Non-Permanent) Freelance Modern Apprentice Graduate Work Experience Placement Agency Worker Business Partner Volunteer Contractor Member of Public Visitor

  • Employee (Permanent)
  • Employee (Non-Permanent)
  • Freelance
  • Modern Apprentice
  • Graduate
  • Work Experience Placement
  • Agency Worker
  • Business Partner
  • Volunteer
  • Contractor
  • Member of Public
  • Visitor

• Involvement

  Select Injured Person Affected Person (No Injury) Witness First on Scene Manager First Aider Security Other Involvement

  • Injured Person
  • Affected Person (No Injury)
  • Witness
  • First on Scene
  • Manager
  • First Aider
  • Security
  • Other Involvement

Injury Assessment

• Severity Level

  Select No Treatment (and return to work) First Aid (and return to work) Professional Medical Treatment Required Restricted Work Absence from Work Major Injury (eg broken bones) Fatal

  • No Treatment (and return to work)
  • First Aid (and return to work)
  • Professional Medical Treatment Required
  • Restricted Work
  • Absence from Work
  • Major Injury (eg broken bones)
  • Fatal

• Injury/Illness

  Select Bruise, graze, scratch Amputation Anxiety/stress Asphyxia Back pain Bump/blow Burn/scald Broken bones(s)/fracture Dislocation (without fracture) Cut/laceration Puncture/penetration injury Foreign body Crush injury Chemical burn Electric shock/burn Effects of smoke Fatal Injury Hernia Loss of sight (temp or perm.) Sprain/strain Other injury No apparent injury Unknown N/A

  • Bruise, graze, scratch
  • Amputation
  • Anxiety/stress
  • Asphyxia
  • Back pain
  • Bump/blow
  • Burn/scald
  • Broken bones(s)/fracture
  • Dislocation (without fracture)
  • Cut/laceration
  • Puncture/penetration injury
  • Foreign body
  • Crush injury
  • Chemical burn
  • Electric shock/burn
  • Effects of smoke
  • Fatal Injury
  • Hernia
  • Loss of sight (temp or perm.)
  • Sprain/strain
  • Other injury
  • No apparent injury
  • Unknown
  • N/A

• Part of Body

  Select Abdomen Ankle Arm Back/spine Chest Ear Elbow Eye Face Finger Foot Groin Hand Head Hip Internal Knee Leg Lung Mouth Neck Shoulder Toes Wrist N/A

  • Abdomen
  • Ankle
  • Arm
  • Back/spine
  • Chest
  • Ear
  • Elbow
  • Eye
  • Face
  • Finger
  • Foot
  • Groin
  • Hand
  • Head
  • Hip
  • Internal
  • Knee
  • Leg
  • Lung
  • Mouth
  • Neck
  • Shoulder
  • Toes
  • Wrist
  • N/A

• Area

  Select Upper Lower Inner Outer Cheek Chin Forehead Jaw Nose Thumb Index finger Middle digits Sole Big toe Little toe Back of hand Palm of hand Front Back Lips Inside mouth Teeth Unknown N/A

  • Upper
  • Lower
  • Inner
  • Outer
  • Cheek
  • Chin
  • Forehead
  • Jaw
  • Nose
  • Thumb
  • Index finger
  • Middle digits
  • Sole
  • Big toe
  • Little toe
  • Back of hand
  • Palm of hand
  • Front
  • Back
  • Lips
  • Inside mouth
  • Teeth
  • Unknown
  • N/A

• Side of Body

  Left

  Right

  N/A

• Injury Comments

Treatment Details

• Was treatment given?

  Select No treatment given Treatment offered but refused Yes - at scene Yes - at local first aid point Yes - at occupational health Yes - at local GP surgery Yes - at hospital Yes - at NHS walk-in centre

  • No treatment given
  • Treatment offered but refused
  • Yes - at scene
  • Yes - at local first aid point
  • Yes - at occupational health
  • Yes - at local GP surgery
  • Yes - at hospital
  • Yes - at NHS walk-in centre

• When was treatment given?

  Date

• Who provided the treatment?

  Select First Aider Doctor Occ Health Nurse Bystanders Customer Line Manager Other

  • First Aider
  • Doctor
  • Occ Health Nurse
  • Bystanders
  • Customer
  • Line Manager
  • Other

• Nature of treatment:

After Initial Treatment

• What happened after the initial treatment?

  Select Return to work Resumed normal activities Sent or taken to hospital Referred to hospital Referred to dentist Referred to own GP Sent or taken home Other Not known

  • Return to work
  • Resumed normal activities
  • Sent or taken to hospital
  • Referred to hospital
  • Referred to dentist
  • Referred to own GP
  • Sent or taken home
  • Other
  • Not known

• Mode of transport (if leaving site)

  Select Company vehicle Hospital vehicle Private vehicle Taxi Ambulance Air ambulance Other means Not known N/A

  • Company vehicle
  • Hospital vehicle
  • Private vehicle
  • Taxi
  • Ambulance
  • Air ambulance
  • Other means
  • Not known
  • N/A

About the Accident/Incident

• Where did this occur

  Home Service & Supply Location

  Overseas

  Production location

  Sky Premises

• Area (if at customers property)

  Select Driveway Garden Hallway In the van Kitchen Living room Loft Pavement Roadway Stairs Other

  • Driveway
  • Garden
  • Hallway
  • In the van
  • Kitchen
  • Living room
  • Loft
  • Pavement
  • Roadway
  • Stairs
  • Other

• Weather/Environment

  Select Wet Dry Icy Windy Extreme heat Extreme cold Other

  • Wet
  • Dry
  • Icy
  • Windy
  • Extreme heat
  • Extreme cold
  • Other

• If OTHER, provide details

• Give as much detail as you can about: weather or ground conditions, names of substances and equipment involved; circumstances leading up to the event, part played by all people involved and what the injured personas doing at the time of the incident.

• What were the sequence of events leading up to this incident taking place?

• What was the immediate cause of this incident?

• What equipment was being used at the time of the incident?

  Select Hammer Drill Step Ladder Single Section Ladder Double Section Ladder Triple Section Ladder CAT Ladder Microlite Laddermate Harness Rope Grab Kernmantle Rope Cows Tail Other

  • Hammer
  • Drill
  • Step Ladder
  • Single Section Ladder
  • Double Section Ladder
  • Triple Section Ladder
  • CAT Ladder
  • Microlite
  • Laddermate
  • Harness
  • Rope Grab
  • Kernmantle Rope
  • Cows Tail
  • Other

• What PPE was being used at the time?

  Select Safety Boots Hard Hat Gloves Safety Goggles Ear Defence Dust Mask Knee Pads

  • Safety Boots
  • Hard Hat
  • Gloves
  • Safety Goggles
  • Ear Defence
  • Dust Mask
  • Knee Pads

• What Happened

• Add any relevant photos

  Media

• Add sketches (if needed)

  Drawing

• Were all of the correct procedures being carried out at the time?

  Yes

  No

• If NO, please describe why not.

• What was the Root Cause of this incident?

  Select Manual handling Slip,trip,fall same level Animal or Insect Fall from height Use of hand tools Use of power tools Contact with electric Struck by object Step on strike against Struck by moving vehicle

  • Manual handling
  • Slip,trip,fall same level
  • Animal or Insect
  • Fall from height
  • Use of hand tools
  • Use of power tools
  • Contact with electric
  • Struck by object
  • Step on strike against
  • Struck by moving vehicle

• What time scale has been set to implement these actions?

• Are extra resources required to assist the implementation of these actions?

  Yes

  No

• ...If YES, what are they and who have you contacted to arrange them?

• Have you fully implemented you Action Plan?

  Yes

  No

Agreement

• I agree that the information contained on this form is correct as far as I am aware.

• I understand that the company will use this information to meet its Health and Safety reporting and recording legal duties and for internal management purposes

• Managers Signature

  Sign