QMF 401 Accident Incident or Near Miss report

Title Page

Use this form to report any adverse event, for example any Accident, Incident or Near Miss that has occurred. Please provide as much information as possible, as soon as you are notified, as this will help in any investigations that may be required.

Once completed send the completed form to SHEQ Department sheq@mdgroup.co.uk.

The SHEQ Department will review the form and will provide guidance as to the next steps, for example initiating a full investigation, the taking of witness statements, reporting to the Health and Safety Executive (RIDDOR) and MD Groups insurance company.

Remember that the law requires that we report any injury that results in over 7 consecutive days (this includes weekends) off work, also injuries to members of the public or any other person affected.

Our insurance company requires us to report any injury that results in 3 days off work. If in doubt, contact SHEQ Department.

Below is some guidance on what an accident, incident or near miss is, if in doubt report it.

What is a Near Miss? - an unplanned event that did not result in injury, illness, or damage – but had the potential to do so.
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

What is an Accident? - unwanted, unplanned event which causes a loss, injury, or illness
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
• Falls from height e.g., a ladder or scaffolding or van
• Contact with hazardous chemicals

Incident Examples
• Incidents or threats of violence or aggression
• Impact on person security
• Trespassing

SECTION 1: EVENT DETAILS

1. Date of event:
2. Time of event:
3. Details of event – was it an accident, incident or near miss?
4. Location of event being report:
5. Client:
6. One Serve/Job Number:
7. MD Group regional office location:
- Poole
- Abingdon
- Exeter
- Bristol
- Bridgwater
- Gloucester
- Stroud
8. Name and contact details of Operations Manager:
9. Name, job title and contact details of person completing form:
10. Was the person completing this form witness to the event?
11. If the answer to Question 10 above is ‘No’, have contact details of witnesses to the event been taken? Provide details in Section 4 below
12. Have witness statements, photographs, etc. been taken and submitted with this form? Provide details in Section 4 below
13. Who was involved in the event, Operative, Sub Contractor or Member of the Public?
Name & Job Title:
Company Name & Contractor's name:
Title and Name:
14. Was an injury sustained as a result of the event? Provide details in Section 2 below
15. Did the injury result in First Aid treatment, visit to GP or clinic and/or Hospitalisation? Provide details in Section 2 below
16. Where the event involved an employee, has the employee taken time off work as a result? Provide details in Section 2 below
17. Were the emergency services called to the site of the event? Provide details in Section 2 below
18. Has the Operations Manager been informed? Provide details in Section 3 below
19. Has the client been notified? Provide details in Section 3 below
20. Has the completed form been sent to SHEQ? Provide details in Section 3 below

SECTION 2: SUMMARY OF WHAT HAPPENED

• Provide as many details as possible of what happened, including any injuries, damage to property etc.
• Include photographs/diagrams as this helps us understand the situation better
• Where there is an injury add details of what the Injured Person was doing at the time of the event and if they received treatment, taken to hospital
• Make a note of tools and PPE being used – take photographs where possible
undefined

SECTION 3: ACTION TAKEN FOLLOWING EVENT

1. Where relevant, was the location where the event took place made safe? Provide details:
2. Where relevant, has the client been informed of any unsafe condition that remains? Provide details:
3. Have risk assessments/method statements/CPP Packs been reviewed and are there any changes recommended? Provide details:
4. Where an employee was involved, have all training records been reviewed? Provide details:
5. Where a contractor was involved, are they CHAS accredited and have their risk assessments/method statements been reviewed and are there any changes recommended? Provide details:
6. Where there is an absence from work has SHEQ/HR been notified? Provide details:
7. Has the client been notified? Provide details:
8. Has SHEQ/Operations Manager been notified? Provide details:
9. Provide any other details of action taken after the event:

SECTION 4: WITNESS STATEMENTS/RECORD OF MEETINGS

Provide details of witnesses and where statements/meetings have taken place provide details and send copies to SHEQ Department SHEQ@mdgroup.co.uk
undefined

What to do after filling in this form?

• 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.