Corporate Health, Safety & Wellbeing Service
HS1
Employee Accident / Incident / Near Miss Investigation Report Form
Reporting Directorate: (please tick) / People / Place / Corporate Services
Service Unit: / Section:
1. About the Injured Person
Name in full: / Pay No: / Age:
Address: / Job title:
Postcode: / Gender:
If under 18, name of person responsible for their supervision:
Signature of Injured Person (if appropriate)
Did anyone witness the incident? / Yes No / If Yes please attach witness statement
Witness details: (Give name and contact details of any witnesses below)
Name(s): / Contact details:
Name(s): / Contact details:
2. About the Incident
Name of person reporting incident: / Pay No:
Contact telephone: / Contact email:
Date of incident: / Time of incident :
Date incident reported / Address where incident took place:
Precise location on premises:
What activity was being carried out at the time of the incident?
What happened? Continue on a separate sheet if necessary. Record details of anything that may have contributed to the incident (e.g. poor weather, icy conditions, lighting, wet floors etc)
If a road traffic incident, were the Police informed? (Provide incident number)
What was the injury? / What part of the body was injured (left/right)?
3. First Aid Details
First aid provided? / Yes No Declined / If yes, give details of first aid provided:
Contamination of blood/fluids/contact with sharps - Has the blood borne infection record been completed? / Yes No
Name first aider: / Signature:
4. For Completion by Manager / Supervisor / Head Teacher
Name: / Job Title: / Contact:
The following information is essential to establish if Corporate Health and Safety service are required to report this incident to Health & Safety Executive (HSE) under RIDDOR 2013. Please do not leave blank.
Do you expect the employee to lose time off work? / Yes
No / If yes, more than 7 days? / Yes
No / Total days lost:
Did the incident result in an over 24 hour stay in hospital? / Yes No
What was already being done to try to prevent this kind of accident from happening?
Preventative Measures / Yes / No / Details
Were Risk Assessments in place?
Has relevant instruction, training & supervision been provided?
Was PPE provided & being worn /used?
Any other actions in place
Action taken to make the situation/environment safe: (eg Area cordoned off / report premises defects to Facilities Management Section)
Action taken to avoid a recurrence: (Use separate sheet if necessary)
Will risk assessments be reviewed as a result of this incident? / Yes No
Have you attached any photographs in relation to this incident? / Yes No
Signature: / Date:
Thank you for reporting and investigating this incident which will help reduce the likelihood of re-occurrence. Please forward this form to the Corporate Health, Safety & Wellbeing Service by email to ; by Fax to 01792 635352 or post to Room 148, Guildhall, Swansea, SA1 4PE.
This form should be returned with all information completed within 5 days of the Incident Occurring. In the event of a serious incident / fatality occurring Corporate Health & Safety should be contacted at the earliest opportunity
This section is for the Corporate Health, Safety & Wellbeing Service use only
Receiving Officer / Date: / Inv FormatRIDDOR reportable? / Yes / No / RIDDOR Ref / Date:
Process type / Incident type / Lost time
Document No: F001:01-15/3 2 of 2