Title Page
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This form is required to be completed and returned within the first 24 hours. This is required under the policy of Next Energy Solutions and current Health and Safety law, for reporting purposes. Please remember the completion of this form benefits the organisation and no blame will be attached to those assisting with the investigation.
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Where did the accident happen?
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Conducted on
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Prepared by
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Contract
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Name of Injured Person
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Title
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Full address of injured person
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Post code
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Gender
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Phone number
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Age (if unknown put 999)
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Injured persons employment status
- Employee
- Work experience
- On a training scheme
- Self employed and at work
- Employed by someone else
- Member of the public (includes pupils, students, customers, patients)
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Injured person occupation or job title
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NOTE:
This document is designed to respond to accidents, incidents and near misses. This will enable the organisation to consider control which ultimately prevent accidents from occurring.
Incident Details
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Enter job description / type of work
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Date and time of incident
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Description of accident, incident, near miss
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Were there any injuries?
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Description of injury
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Take photo of injury
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If a fall from height, how high was the fall?
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*Main factor involved in the incident
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Was there any damage to property or plant?
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Description of damage
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Take photo of damage
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Describe what happened (give as much detail as you can, including i) the events that led to the incident ii) the operation or activity in progress. Describe any action taken to prevent similar incidents occurring)
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Take photo of surrounding environment including any annotations
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What actions will be taken to eliminate future repeats of the incident?
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Management comments
Sign Off
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Supervisor sign off
