Title Page
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Conducted on
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Prepared by
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Location
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What are you Reporting
Form
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Please use this form to report any Near Miss or Accident/ Incident related to SHEQ that you have had or witnessed whilst at work. Please provide as much information as possible
Near Misses
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What is a Near Miss? - an unplanned event that did not result in injury, illness, or damage – but had the potential to do so
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Examples:
• A falling object that hits the ground in front of you
• A minor trip on a damaged piece of carpet or trailing cables that does not result in you falling over
• Temporarily losing your footing on a slippery floor
• Spill hot drink whilst walking around
• Nearly collide into colleague whilst entering/ exiting room
Accidents
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What is an Accident? - unwanted, unplanned event which causes a loss, injury, or illness
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Examples:
• Slipping and falling to the ground
• Banging your hand, leg, or head on something
• Discovering asbestos
• An incident where a minor injury such as a cut, bruising or mild pain has been experienced.
• Scalded by hot liquid or surface
• Electric shock
• Fall from a ladder or foot stool
• Falling off your chair
Incidents
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Examples:
• Incidents or Threats of violence or Aggression
• Impact on person security
• Trespassing
Details
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This form is to be completed by the Employee, Line Manager, Designated Managers
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Date & Time of Accident/Incident:
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Client:
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Location of Incident:
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One Serve/Job Number:
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MD Group Regional Office Location:
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Name and Contact Details of Operations Manager:
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Name, Job title and Contact Details of person completing form:
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Was the person completing this form witness to the incident?
DETAILS OF INJURED PERSON
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Injured Person
- Employee
- Sub-Contractor
- Third Party i.e Member of the Public
Third party: i.e. Member of the Public □
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Gender
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DOB
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Full Name, Job Title & Trade of IP:
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Contact Details:
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Name of Line Manager (if employee):
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Contact Details:
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Name of Company (if contractor)
What Happened?
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Provide as many details of what happened – below is a list of things to consider but this is not exhaustive so please be as thorough as you can
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• Add details of the injury, including location on the body
• Include photographs where you can, as this helps us understand the situation better
• Note down any loss of costs attached to the incident i.e. damaged equipment, property damage
• Add details of what the Injured Person was doing at the time of the incident/near miss
• Make a note of tools being used – take photographs where possible
• Make a note of PPE in use – take photographs where possible -
Statement of What Happened
What Happened Following the Event
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What happened after the Near Miss/Accident/Incident – below is a list of things to consider but this is not exhaustive so please be as thorough as you can
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• First Aid Treatment Received?
• Taken to hospital?
• Any absence from work as a result?
• Were the Police or other emergency services called to the scene?
• Was a client representative notified?
• Other, e.g. tenants evacuated from the property -
Statement of What Happened Following the Event
Witnesses
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Where there any witnesses?
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Name of Witness 1
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Contact Details of Witness 1
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Name of Witness 2
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Contact Details of Witness 2
What to do after filling in this form?
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• Sign and date below
• Send completed form to the relevant Operations Manager, HR@mdgroup.co.uk and SHEQ@mdgroup.co.uk
• Attach supporting evidence such as photographs and any other documents you may have such as asbestos report, training records etc.
• SHEQ will review and follow up with an investigation if required.
Person Completing the Form
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Name:
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Signature:
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Job Title:
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Date:
