H&S Incident Report Form

Incident Submission

For accidents, incidents and near misses
Date This Form Is Being Completed*

DayMonthYearHourMinutes
Name of person submitting this form*
What type of report are you submitting?*
DESCRIPTION: All deaths to workers and non-workers, with the exception of suicides, are RIDDOR reportable if they arise from a work-related accident, including an act of physical violence to a worker.
DESCRIPTION: There are a list of reportable ‘specified injuries’ as set out in RIDDOR 2013. This includes fractures (other than to fingers, thumbs and toes), amputations, any injury likely to lead to permanent loss of sight or reduction in sight, crush injuries to the head or torso causing damage to the brain or internal organs, serious burns (including scalding) covering more than 10% of the body, any scalping requiring hospital treatment, any loss of consciousness caused by head injury or asphyxia.
DESCRIPTION: Accidents must be reported where they result in an employee or self-employed person being away from work, or unable to perform their normal work duties, for more than seven consecutive days as the result of their injury. This seven day period does not include the day of the accident, but does include weekends and rest days. The report must be made within 15 days of the accident.
DESCRIPTION: Accidents must be recorded, but not reported where they result in a worker being incapacitated for more than three consecutive days.
DESCRIPTION: Minor injuries are not RIDDOR reportable and include any non specified injury such as fractures to fingers and toes, bumps, bruises, cuts, abrasions, sprains etc.
DESCRIPTION: Occupational diseases include: carpal tunnel syndrome; severe cramp of the hand or forearm; occupational dermatitis; hand-arm vibration syndrome; occupational asthma; tendonitis or tenosynovitis of the hand or forearm; any occupational cancer; any disease attributed to an occupational exposure to a biological agent.
DESCRIPTION: Dangerous occurrences are certain, specified near-miss events. Not all such events require reporting. There are 27 categories of dangerous occurrences that are relevant to most workplaces, for example:

the collapse, overturning or failure of load-bearing parts of lifts and lifting equipment; plant or equipment coming into contact with overhead power lines; the accidental release of any substance which could cause injury to any person.
DESCRIPTION: A near miss is not RIDDOR repotable as it is an event not causing harm, but has the potential to cause injury or ill health. This could include the following: a trip/stumble, falling objects, agression/conflict situation, encountering a potentially dangerous situation.
This type of report is RIDDOR reportable
What is the name(s) of the person(s) involved in the incident?*
This is your name + the name(s) of any other person(s) who were involved in the incident
Is the named person(s) an employee, direct or agency operative or member of the public?*

EmployeeDirect or Agency OperativeMember of the public
Name of Direct or Agency company*
Which Group Company was carrying out the work at the time of the incident?*
Which Department was carrying out the work at the time of the incident?*
Management Team*
In which location was the work being carried out at the time of the incident?*
Client Name*
If you can't provide a Client Name, please specify yourCompany Name
Site location of the incident*

CLIENT NAME

Site Address

CityState / Province

Site Postcode
Date Incident Occured*

DayMonthYear
DateHourMinutes
Whereabouts on the body was the injury sustained?*
What type of action led to the need to complete this form?*
With every Road Traffic Accident reported it is a requirement to complete the Vehicle Accident Report Form. Please click here to access that form.
Incident details (what occurred to raise the record)*
• Accident / incident details – such as location, historical events, background. • Relevant site details. • Relevant details of conditions, e.g. weather. • A brief factual account of the events that led up to the accident / incident. • A brief account of the management issues affecting the accident / incident.
Was initial first aid carried out?*
What first aid was carried out?*
Following the incident, did the individual*
Photo of location*

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Photo of injury / damage / observation*

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Photo of equipment involved

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Other supporting photo

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Other supporting photo

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Other supporting photo

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I confirm that the detail submitted on this form and correct and understand that a further investigation may be required*

Incident Investigation
Investigation Date*

DayMonthYear
DateHourMinutes
Name of person submitting this investigation*
Is the Incident RIDDOR reportable?*
As the incident is RIDDOR reportable, you must consult with Carney Consultancy and Directors as part of your investigation and prior to it's submission on this form.
Did the Incident occur in an Company office or in the field?*
Use the table below to choose the appropriate investigation based on the severity of the incident.
Investigation Level*
What was the outcome of your Investigation*
- Any damage to plant, property or persons? - Any other persons involved? - How did the accident happen? - Causes of any injuries? - Activities being carried out at the time? - Any witnesses? - Safe Systems of Work in place and followed? - Risk assessments in place? - Were people trained and supervised? - Correct equipment and PPE used? - Risk identified and controlled? - Impacted by work organisation / layout? - Influence by work equipment? - Maintenance or cleaning an influence? - Conditions that may have influenced the accident? - The immediate and underlying causes of the accident/incident? - Reference any similar accidents / incidents.
What remedial action should be put in place to prevent this type of Incident from happening again?*
Any other comments to support your investigation and suggested remedial actions?*
Investigator Signature*

Clear

Investigation Review and Confirmation
Review Date*

DayMonthYear
DateHourMinutes
Name of person submitting this review and confirmation*
Have you reviewed the Investigation and are you satisfied with the outcome?*
Have you reviewed the suggested remedial actions and are you satisfied with their introduction as a means to prevent this type of incident from reoccurring?*
What date should any remedial actions by completed by?*

DayMonthYear
Date
Reviewer Signature*

Clear
Should be Empty:

Incident Submission

Incident Investigation

Investigation Review and Confirmation