Accident (injury caused) Near Miss (no injuries) Report facts only.
SIS Ltd. Health and Safety arrangements require this form to be completed by the Injured Person or by the senior person at the incident location as soon after the incident as possible and be a true and accurate statement of what happened. Please write clearly and complete all appropriate sections. See also the information available on the SIS intranet at SISinfo. This record of an accident or injury is used in place of the Form BI 510 Accident Book under the Social Security (Claims and Payments) Regulations 1979.
SIS Ltd. will use this information to meet Health & Safety and Social Security reporting and recording legal duties. The information is held by SIS HS and seen by relevant SIS managers and agents. Safety Representatives undertaking their statutory functions may carry out an inspection of the area concerned and speak to staff in order to determine the cause of the accident and may request information on this form, including details in Part A. Personal details can only be provided with the consent of the person to whom they relate – see notes and tick boxes below.
Part A – Personal Details of Injured Person
Full Name: / Sex: M F
Staff No (if relevant): / Date of Birth: Age:
Home address: / Tel No:
As the injured person, do you agree to your personal details in Part A being disclosed to Trade Union Safety Representatives, please tick this box
Part B – Employment Details
SIS Ltd. Department or Employer: / Event (if applicable):
Business address:
Job Title / Occupation: / Business Phone number:
Employee Contractor Self Employed Freelance Artist/Contributor Member of Public Other
Part C – Details of Incident or Work Related Ill Health
Date of incident: / Time of incident (24 hrs):
Address at which incident occurred: / Was it a Road Traffic Accident? y/n:
Exact location:
Describe what happened? Give as much detail as you can, e.g. name any substance or equipment involved , events leading up to accident / incident, the part played by any people and what the injured person was doing at the time of the accident.
Continue on a separate sheet or the space overleaf if necessary …
Part C.1- Witnesses. If there are witnesses to the incident – tick this box Record names and addresses overleaf in Part F, - ask THE WITNESSES to complete tick box in this Part to indicate if they consent to disclosure of personal details).
Part C.2 – If other persons injured in this incident– tick this box (Give details if known overleaf – in Part G )
Part C.3 – Person Completing this record.
If you are person named in Part A tick this box , then sign here and go to Part D. / Signature:
Or, if NOT the person in Part A, provide the following details: / Name:
Address:
[Consent YES to these details being disclosed to T.U. Safety Representatives -Tick here / Occupation:
Signature:
Part D – Details of Injury and Resulting Absence
Nature and extent of injury:
What part of the body: / (left or right)
Treatment given by: None Self 1st Aider SIS Occupational Health Hospital Own GP
If absent from work, date and time of first absence: Date - Time -
Date and time of return to work (can be notified later): Date - Time -
Part E1 – Immediate Corrective Action - to be completed by senior person at incident location
What immediate action was taken to prevent a recurrence and by whom?
Continue on a separate sheet if necessary …
Name: / Job title: / Tel. No.:
Signature: / Date:
NOW SEND TO Line Manager of person injured (if they are a SIS employee), or if not, the Line Manager of senior person at incident location
Part E2 – Corrective Action - to be completed by Line Manager
What further action has been/is being implemented to prevent a recurrence and by whom?
Continue on a separate sheet if necessary …
Is further investigation required?: Yes or No / Who will be investigating?
Has the injured person been referred to SIS Occupational Health for return to work fitness assessment?: Yes or No
Name: / Job title: / Tel. No.:
Signature: / Date:
Part F – Witnesses – Names and Personal Details – [From Part C.1]
Witness Names / Witness’ Address / Tel. No / Consent to disclose name etc -Tick Box & Sign
No.1: : / :
No.2: : / :
No.3. : / :
If you are a witness and agree to your name and address being disclosed to T.U. Safety Representatives, tick box above & sign.
Part G – Names and Details of Other Persons Injured in Incident – [From Part C.2]
Other Person Injured Names / Address (if available – BUT there should be separate report form for each person) / Tel. No
if available / NOTE
DO NOT DISCLOSE THESE DETAILS WITHOUT CONSENT
No.1: :
No.2: :
Information for SIS HS ~ Personal details of other persons injured in this incident should be recorded on separate form.
Use this space to provide any further information from Part C:
Continue on a separate sheet if necessary …
LINE MANAGER TO SEND (by e-mail attachment) TO:
June 2009 V2.2