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Accident Report Form

This document is a health and safety incident report form. It requests information about an incident in several sections: details of the incident such as date, time, location; a description of what happened; any injuries sustained and treatment received; witnesses; and contact information for the person filling out the form and the person involved in the incident if different. The final section addresses information sharing and consent for trade union representatives to view the report.

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ratima8721
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49 views

Accident Report Form

This document is a health and safety incident report form. It requests information about an incident in several sections: details of the incident such as date, time, location; a description of what happened; any injuries sustained and treatment received; witnesses; and contact information for the person filling out the form and the person involved in the incident if different. The final section addresses information sharing and consent for trade union representatives to view the report.

Uploaded by

ratima8721
Copyright
© © All Rights Reserved
Available Formats
Download as XLSX, PDF, TXT or read online on Scribd
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OHS1a

Health and Safety Incident Report

Section 1 - About the Incident

1.1 What are you reporting? (Explanation of terms)

1.2 When did it happen? Day: Date: Time:


(24hr clock)
1.3 Where did it happen?

If NE Office, please select:

If not NE Office, please give specific


details. Please provide address or
location (road, building, floor, room,
outdoor location, private residence etc)

1.4 What happened?


Please describe the near miss, accident,
incident, dangerous occurrence etc.,
including events that lead to it, and
details about any equipment, substances
or materials involved.

1.5 What category best describes the incident?

1.6 Witnesses
Name (s) and contact details of anyone
who witnessed the incident.

Section 2 – About the Person involved (if applicable)

2.1 Who was involved?


Name, role and contact details (include
staff number and function name).) Please
include the full address for any volunteer
or third party injured (e.g. Contractor,
visitor, member of the public etc.).

If Near Miss reported – please go to Section 3 after completing 2.1 above.

2.2 What type of injury / illness / disease has been sustained?


Please include which part / side of the
body was affected.
For injuries only:

2.3 What treatment was provided?


Please include whether first aid and/or
hospital treatment was needed

2.4 Did the injured person go straight


back to work afterwards?

If no, please given duration of absence if known

Section 3 – Person Completing this Form – If same as Section 2.1 above, go to Section 4

3.1. Details of the person completing this form (if different to those give in box 2.1 above)
Name, role and contact details (include staff number and Function name). If you are a volunteer
or third party (e.g. a contractor) please include your full address

3.2. Date form completed:

Section 4 – Information Sharing

Trade union appointed safety representatives have a legal right under Safety Representatives and Safety
Committees Regulations 1977 to see all accident reports.
If you are happy for your personal details on this form to be provided to Trade Union appointed safety
representatives then please indicate below.

If you indicate no, we will anonymise the information before disclosure to the Trade Union appointed safety representatives.

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