Incident report form - for accidents, near misses and disease - Spennymoor site
Date of report
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Day
-
Month
Year
Date
Name of person affected by accident, near miss or disease
*
First Name
Last Name
Is the person an
*
Employee
Contractor / Subcontractor
Visitor
Member of the public
Other
Line manager or company name
*
What type of report is being submitted?
*
Near miss
Minor injury
Over 7 day injury
Specified injury
Fatality
Occupational disease
Environmental incident
Date of occurance
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Day
-
Month
Year
Date
Time of occurance
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01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
:
Hour
00
10
20
30
40
50
Minutes
Was incident reported within
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1 hour
Same day
24 hours
48 hours
1 week
Other
Statement of person involved in the incident
*
Location of incident (be as specific as possible - add image of location at end of report)
*
Image of the location of incident
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of
Please give description of injury and or damage
*
Image of the injury or damage
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of
Tools, equipment etc. involved in the incident
*
Image of the tools, etc.
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of
Witness/Witnesses (will be contacted where additional information is required)
*
If an injury was sustained did the individual (tick all that apply)
Not require first aid and returned to work.
Received first aid on site and returned to work.
Received first aid on site and then went to doctor/walkin/hospital
Received first aid from a paramedic then returned to work
Receive first aid from paramedic then taken to hospital for further assessment / treatment
Go to own walkin/doctor / hospital after their shift was completed.
Person who completed form
*
First Name
Last Name
Title/position if not the injured party
*
The details contained in this form are as accurate as possible (to be signed by person involved with incident).
*
Date
-
Month
-
Day
Year
Date
Submit
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