Title Page
-
Incident location
-
Prepared by
-
Is the incident reportable to RIDDOR?
-
Specify the incident.
RIDDOR Report
Section 1: Company and Incident Reporter Information
-
Name of company/organisation
-
Address of company/organisation
-
Name of incident reporter
-
Job title
-
Contact number
-
Email address
Section 2: Person(s) Affected
-
Person Affected
-
Name
-
Date of birth
-
Home address
-
Contact number
-
Job title
-
Position
-
Specify
Section 3: Incident Information
-
Date of the incident
-
Time of the incident
-
Location of the incident
-
Specify which department or area the incident took place.
-
Specify the exact location.
-
Kind of incident
- 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
- 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, a harmful substance
- Exposed to fire
- Exposed to an explosion
- Contact with electricity or an electric discharge
- Injured by an animal
- Physically assaulted by a person
- Other type of incident
-
How high was the fall (in metres)?
-
Specify the type of incident.
-
Are there any witnesses?
Witness
-
Name
-
Contact information
Section 4: Incident Description
-
Describe in detail what happened, why the incident occurred, and other helpful information. You can also capture photos or videos of the incident to give proper context.
-
Incident description
Section 5: Details about the Injury
-
Description of the injury (what it is, which body parts are affected, etc.)
-
Photo of the injury
-
Severity of the injury
- Fatal
- Major
- Injury to an employee or self-employed person which prevented them from doing their normal work for more than 3 days
- Injury to a member or the public which meant they had to be taken from the scene
-
Was any first aid administered on the site?
-
What treatment was provided?
-
Who administered the treatment?
-
Was the victim taken to the hospital immediately?
-
Which hospital were they brought to?
-
What treatment was provided?
-
How long did they stay in the hospital?
Sign-off and Completion
-
Recommendations
-
Name and signature of incident reporter
-
Job title