Title Page
-
Name of injured person
-
Date and Time of accident
-
Prepared by
-
Location
-
Site H&S contact name
-
Site H&S contact phone number or email
-
Safety briefing provided by site
-
Image of briefing if available
Report
Details of Injured Person
-
Date of Birth
-
Mobile Telephone Number
-
Home Address
-
City
-
County
-
Post Code
-
Gender
Injury Details
-
What part of the body was injured? Describe in detail
-
Take photo of the body part that was injured. Annotate as required
-
What was the nature of the injury? Describe in detail
-
Describe fully how the accident happened?
-
What was the employee doing prior to the event?
-
Take photos of the surrounding environment the employee was in prior to the event
-
Was tooling and /or equipment being used?
-
Detail what was being used
-
Was PPE in use?
-
Detail what PPE was in use
-
Cause of event
- Unsafe Act
- Unsafe Conditions
- Unsafe Equipment
- Unsafe Use of Equipment
- Incorrect use of or lack of PPE
-
Add supporting evidence of contributing factors
-
Was work being carried out covered by RAMs?
-
Add photo of the document
-
Accident result of an existing condition?
-
Next of kin contacted?
-
Person contacted
-
Send home/off site?
-
Returned to work?
Witness Statements
-
Were there any witnesses?
-
Add witness
Witness
-
Enter witness name
-
Contact number
-
Witness statement
-
Witness signature
Emergency Services
-
Employee went to doctor/ hospital?
-
Hospital Name
-
Police were called to the scene
-
Police reference number
Comments
-
Use this space to capture any further details
Sign off
-
Injured person signature
-
Reported by signature
Important Instruction
-
The following people must be notified of the accident immediately: Your site contact, your line manager, HS&E manager & HR Manager
-
I confirm all of the above parties have been notified of the accident reported above.
