Health and safety report of injury or dangerous occurrence

This form is part of legislation known as RIDDOR (The Reporting of Injuries, Diseases and Dangerous Occurrences Regulations Act, 2013).

It must be completed by the manager, officer in charge, head teacher or supervisor of the location, establishment or work activity.

There are several parts to the form, and you will be required to give detailed information about the incident and the injured person. Please note - if you have a report of multiple people being injured, you will have to complete a form for each person.

The fields marked with an asterisk (*) are required fields. All the information you enter will be submitted securely.

Part 1 of 6 - About You

* Full name:

* Job Title:

* Your responsibility:

I am the injured person’s line manager

I am the manager of the location where the accident happened

* Work telephone number:

Email address

Confirm Email address

Email addresses do not match.

* Departmental address and postcode:

* Did the incident happen at this address?

Yes

No

Part 2 of 6 - About the Incident

* Date of incident (dd/mm/yyyy)

* Time of Incident (use the 24-hour clock such as 0600)

* You stated the incident occurred at your work address -
exactly where did the incident happen?

* You stated the incident didn't happen at your work address -
where did the incident happen?

Please select Elsewhere in the Council At someone else’s premises In a public place

* Please give the name, address and postcode of the premises:

* Give details of the public place where it happened:

Part 3 of 6 - About the injured person

* Full name:

* Home address and postcode:

* Home telephone number:

* Age:

* Gender

Please select Male Female

* Ethnicity:

* Job Title:

* Which one of the following describes the injured person?

Council employee

trainee

volunteer

on work experience

employed by someone else

self-employed and at work

service user

member of the public

pupil

* Employee number

* Give details about the trainee's position:

* Please give the name and address of the employer:

Part 4 of 6 - About the injury

* What was the injury (for example fracture, cuts)?

* What part of the body was injured (for example, left hand / right eye)?

* Which one of the following describes the injury?

a fatality

a specified injury

happened to an employee or self-employed person which prevented them from doing their normal work for more than 7 days

happened to an employee which prevented them from doing their normal work for 7 days or less

happened to an employee which resulted in no lost time

happened to a member of the public which meant they had to be taken from the scene of the accident to a hospital for treatment

none of the above

* Please state for how many days

* Did any of the following happen to the injured person (tick all that apply):

become unconscious

need resuscitation

remain in hospital for more than 24 hours

none of the above

Part 5 of 6 - About the accident

* Select one description which best bescribes what happened:

Contact with moving machinery or material being machined

Hit by moving

flying or falling object

Hit by a moving vehicle

Hit something fixed or stationery

Injured while handling

lifting or carrying

Slipped

tripped or fell on the same level

Fell from a height

Trapped by something collapsing

Drowned or asphyxiated

Exposed to or in contact with a harmful substance

Exposed to fire

Exposed to an explosion

Contact with electricity or an electrical discharge

Injured by an animal

Physically assaulted

Another kind of accident

* How high was the fall (in metres)?

* You must complete a Abuse, Aggression and Violence Incident Report form. Please agree you will do this:

I agree to complete the Abuse Aggression and Violence Incident Report form

* Please describe the other kind of accident

Part 6 of 6 - About what happened

* Give as much detail as you can about what happened.
For instance:

• the name of any substance involved
• the name and type of any machine involved
• the events that led to the incident
• what the injured person was doing
• the role of any other people

* Describe the practical action you have taken to prevent a similar incident happening again. This may include changing work practices, providing extra training or issuing additional protective equipment.