Directorate

Business Unit

London/Chatham/Off-Site Location

PART A - ABOUT THE AFFECTED PERSON

Surname Forename

Address

Post Code

Telephone Number

Occupation/Job Title

Status

Employee Contractor

Member of PublicVisitor

Date of Birth Male Female

PART B - ABOUT THE INCIDENT

Date it happened Time it happened (24 hr clock)

Address where it happened (On-Site or Off-Site)

Exact location within premises or Off-Site

Incident Category:

Near Miss

Work Related Accident

Physical Assault

Property Damage

Ill Health

Verbal Abuse

Other

Briefly describe the event. Use a separate sheet if required.

Was the injured person taken to hospital?

Yes No

Hospital

PART C - ABOUT THE INJURY

Was any physical injury sustained? (Please X)

Yes No If no continue to Part D

What was the injury (e.g. fracture, laceration, burn)?

Which part of the body was injured?

Please ensure this form is sent to Trevor Jennings, Risk Manager, Gallery 6 London

Please circle on the diagram below

(Click on red circle and move with arrow keys (word version only)

FRONT VIEW BACK VIEW

Did the injury require First-Aid Treatment?

Yes No

If Yes, who administered First-Aid?

Name

Part D - Other people involved

Name & Address of any witness(es) (if any)

Name and address of assailant (if applicable)

Part E - Reporting Details

Details of the person reporting the incident /accident, if other than the affected person.

Name

Occupation

Address & Telephone Number

Incident/accident was reported:

Date Time

Signature of person reporting incident

PART F –RISK MANAGER USE ONLY

Name of Line Manager of Injured/Affected Person

Title:

Telephone Number:

Detail investigation findings and what action has been taken to prevent a reoccurrence of the incident. Use a separate sheet if required.

Was the injured person able to return to normal duties immediately following the accident?

No Yes

If No: Date Returned To Work

If RIDDOR Reportable Date Reported/ReferenceNo.

Date Report Form Received

Date Details Entered on Database

Signature of Risk Manager

Please ensure this form is sent to Risk Manager, Gallery 4London