VIN.HS.1062 Vindex Systems Incident and Near Miss Report Form

Site Details and Job Information

• Client / Site

• QVIN / Site Name (If Applicable)

• Site Address
  Address

• Conducted on

  Date

• Prepared by

• Are you reporting a Incident or Near Miss?

  Incident

  Near Miss

1. Information about the person who has had the incident.

• Name

• Injured Person Employment Status

  Select Vindex Employee Sub-Contractor Member of the Public Other

  • Vindex Employee
  • Sub-Contractor
  • Member of the Public
  • Other

• Has the person suffered any injury, if so what are the injuries and what treatment provided?

• Did the injured Person attend a site induction?

  Yes

  No

  N/A

• Was the injured person wearing the appropriate PPE?

  Yes

  No

  N/A

3. Information about the Incident / Near Miss

• When did the Incident / Near Miss happen.

  Date

• Where did the Incident / Near Miss happen. State which area or place etc.

• How did the Incident / Near Miss happen? Give the cause of the Incident / Near Miss if possible.

• 1 - Near Miss / Dangerous Occurrence 2 - Minor Injury (First Aid Response 0-3 days Lost Time) 3 - Medium Injury (Escalation in Treatment ie Hospital 3-7 Days Lost Time) 4 - Major injury / RIDDOR or +7 Days Lost Time

• Corrective Actions - What steps should be taken to prevent a reoccurrence of the Incident or Near Miss?

• Reportee Signature

  Sign

• Date

  Date

4. For the employee only

• By ticking this box I give my consent to my employer to disclose my personal information and details of the accident which appear on this form to safety representatives of the employee safety team for them to carry out the health and safety functions given to them by law.

• Employee Signature

  Sign

5. Please email to your Line Manager and Charlotte Finlayson-Green for review