Near Miss Report
Incident Report
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Incident Report
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Incident Report
Incident Report
1 – General Information and Immediate Action
Type:
Accident
Incident
Near Miss
Vehicle Incident (no 3rd party)
Site:
Date
DD slash MM slash YYYY
Time
Hours
:
Minutes
AM
PM
AM/PM
Person(s) Involved:
Add
Remove
Location of Accident / Incident:
2 – Nature of Injury:
Bruise
Cut / Abrasion
Burn
Sprain / Strain
Head Injury
Eye Injury
No Injury Sustained
Vehicle Damage sustained
Other (please specify)
Other Description: Cut to operatives’ finger, crushing may have created floating bone fragment, etc.
Other
Vehicle Reg Number
Picture of injury or damage to vehicle
(Required)
Max. file size: 2 MB.
Action taken by First Aider
Untitled
No treatment given
Back to work
Third Choice
Sent to hospital
Advised to consult GP
Further details (if required)
3 – What PPE was being worn by the injured person(s):
Safety Boots
High Visibility Clothing
Hard Hat
Gloves
Safety Glasses
Ear Protection
4 – Details of the event:
Describe how the Accident / Incident happened (as accurately as possible):
Signature (injured person)
Date
DD dash MM dash YYYY
Time
Hours
:
Minutes
AM
PM
AM/PM
Signed (First Aider)
Date
DD dash MM dash YYYY
Time
Hours
:
Minutes
AM
PM
AM/PM
5 – Witnesses (list below details of any witnesses):
Name
Department / Company Names
Contact Details
Add
Remove
6 – At the time of the Accident:
Was the injured party carrying out their normal duties?
Were they authorised to be doing what they were doing at time of the accident / incident?
Were relevant systems of work or procedures being followed?
Had they received the correct training?
Had they received the correct training?
Was the injured party on their normal shift?
Was the injured party able to continue working?
Was the correct PPE being worn?
Photographs taken?
7 – Supporting Documents:
F2508 (if applicable)
Risk Assessment(s)
Specialist Assessment ( e.g. COSHH, Manual Handling)
Work Control Permit
Photos of incident / damage to vehicle
Training Record (including any induction records)
Safe Systems of Work
Witness Statements
Police Report / ref number (vehicle incident only)
Other (please state)
Additional Documents
8 – Immediate Cause of the Accident / Incident:
9 – Root Cause of the Accident / Incident:
10 – Immediate Corrective Action Taken:
11 – Preventive Action to be Implemented following the Investigation:
12 – What further action or investigation is required?:
13 – Statistical Information:
Actual Severity
Minor
Lost Time (any duration)
Major Injury (or suspected major injury)
Fatality
Potential Severity
Potential Severity
Minor
Lost Time (any duration)
Major Injury (or suspected major injury)
Fatality
Was the accident / incident RIDDOR Reportable?
Yes
No
Date F2508 Submitted:
DD dash MM dash YYYY
Reported by:
Signature (Supervisor)
Time
Hours
:
Minutes
AM
PM
AM/PM
Date
DD dash MM dash YYYY
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