Report of an Injury or Dangerous Occurrence (Draft)

• Site Address of Incident

  Select

• Prepared by

• Is this incident RIDDOR reportable.

  Yes

  No

  N/A

• What is the incident?

  Select Fatality Major Injury or Condition Injury to an Employee or Self-Employed Person (which prevented them doing their normal work for more than 3 days) Injury to a Member or the Public (who had to be taken from the scene of the accident to a hospital for treatment)

  • Fatality
  • Major Injury or Condition
  • Injury to an Employee or Self-Employed Person (which prevented them doing their normal work for more than 3 days)
  • Injury to a Member or the Public (who had to be taken from the scene of the accident to a hospital for treatment)

• Please report to RIDDOR - 0345 300 9932, https://www.hse.gov.uk/riddor/report.htm

SECTION A - About you

• Full Name

• Job Title

• Telephone Number

• Name of your Organisation

• Organisation Address and Postcode.

• What type of work does your Organisation do.

Section B - About the Incident

• On what date did the incident happen?

  Date

• At what time did the incident happen?

  Date

• To whom was the incident reported?

• Location of incident. (Specify site location)

• Where there any witness(es)?

  Yes

  No

  N/A

• If yes, provide name(s) and contact details.

Part C - About the injured person

• Full Name

• Home Address and Postcode

• Telephone Number

• Email Address

• Age

• Are they

  Male

  Female

• What is their job title?

• Is the injured person.

  Select One of your employees On a training scheme On work experience Employed by someone else Self-employed and at work A member of the public

  • One of your employees
  • On a training scheme
  • On work experience
  • Employed by someone else
  • Self-employed and at work
  • A member of the public

• How many days was this person prevented for their normal work duties.

Part D - About the injury

• What was the injury? (eg fracture, laceration)

• What part of the body was injured?

• Photo of Injury

  Media

• Was the Injury (Please select one answer)

  Select Fatality Major Injury or Condition Injury to an Employee or Self-Employed Person (which prevented them doing their normal work for more than 3 days) Injury to a Member or the Public (who had to be taken from the scene of the accident to a hospital for treatment)

  • Fatality
  • Major Injury or Condition
  • Injury to an Employee or Self-Employed Person (which prevented them doing their normal work for more than 3 days)
  • Injury to a Member or the Public (who had to be taken from the scene of the accident to a hospital for treatment)

• Did the injured person? (Please tick all that apply)

  Select Become Unconscious Need Resuscitation Remain in hospital for more than 24 hours None of the above

  • Become Unconscious
  • Need Resuscitation
  • Remain in hospital for more than 24 hours
  • None of the above

Part E - About the kind of accident

• Please select what best describes what happened.

  Select Contact with moving machinery or material being machined Hit by a moving, flying or falling object Hit by a moving vehicle Hit something fixed or stationary Injured while handling, lifting or carrying Slipped, tripped or fell on the same level Fell from a height Trapped by something collapsing Drowned or asphyxiated Exposed to, or in contact with harmful substance Exposed to fire Exposed to an explosion Contact with electrical discharge Injured by an animal Physically assaulted by a person Another kind of accident

  • Contact with moving machinery or material being machined
  • Hit by a moving, flying or falling object
  • Hit by a moving vehicle
  • Hit something fixed or stationary
  • Injured while handling, lifting or carrying
  • Slipped, tripped or fell on the same level
  • Fell from a height
  • Trapped by something collapsing
  • Drowned or asphyxiated
  • Exposed to, or in contact with harmful substance
  • Exposed to fire
  • Exposed to an explosion
  • Contact with electrical discharge
  • Injured by an animal
  • Physically assaulted by a person
  • Another kind of accident

• How high was the fall in meters?

• Describe what happened ( Give as much detail as you can, name any substances, machines involved, events that led to the incident, parts played by any people.)

• Attach any photo evidence.

  Media

• Signature

  Sign