This Form Must Be Completed for Any Accident Or Incident Involving Aberness Care Staff

Accident / Incident Report Form

This form must be completed for any accident or incident involving Aberness Care staff, which occur on company owned or managed premises, or during the course of any assignment. It should be used to report all incidents and accidents; work or premises related accidents and ill health; acts of violence (physical and verbal abuse and threats to staff); injuries arising from road traffic accidents whilst at work and non injury incidents that had the potential to cause harm (dangerous occurrences or “near misses”).

Please complete the form providing factual and accurate information only, and then forward it to your line manager within 24 hours of the incident. Serious incidents must be reported immediately by calling the Aberness Care mainlines: 07734931098 or 07734946224. Further information on the Accident/Incident Reporting policy can be found on our website or in the main office.

Section 1 of the form should be completed by the affected / injured person, their representative or a witness to the incident. If you are unsure what to write, please contact your line manager who will assist you. Section 2 will be completed by your line manager.

Data Protection Act 1998: The information provided on this form will be processed in accordance with the Data Protection Act and will only be disclosed within Aberness Care to members of staff who need to know it in order to carry out their duties, e.g. work colleagues, care manager, etc. Relevant information will be disclosed outside the University where it is required by law to do so. In the event of a personal injury claim, information may be disclosed to the company's Insurers. Anonymised data may also be disclosed to relevant trade union officials

Section 1 – About the Incident
What are you reporting? (please circle) / Incident / Accident / Violence at Work / Near Miss / Dangerous Occurrence
Name of person reporting incident:
Department: / Contact details: (e-mail / login):
Incident reported: / Date: / Time:
Date of incident: / Time of Incident:
Precise Location:
What was being done at the time of the incident:
What happened: Continue on a separate sheet if necessary. Please record details of anything that may have contributed to the incident (e.g. icy conditions).
Nature of harm / ill health / damage:
Injuries: (Please give details of injuries sustained as a result of the incident, what was the injury e.g. fracture, laceration
About the person affected
Name in full:
Address
Contact details: / e-mail: / Telephone:
Department: / Position (employee):
Age: / Gender (circle): / Male / Female
Status: / Employee / Service User / Visitor / Contractor / Other (specify):
Signature of injured person (or the responsible adult if under 16):
Witness details: Give name and contact details of any witnesses below:
Name(s): / Contact details:
Treatment details (If a First Aider attended he/she should complete this section)
First aid provided: / Yes / No / NA / Time of attendance:
If Yes give details:
Name of person giving First Aid: / Signature:
Section 2 - Post incident action, to be completed by Line Manager
What happened to the injured person afterwards: Please circle below:
Taken directly to hospital / Went home / Returned to work/activity / Other: Specify:
Was the incident due to possible defects in premises, equipment, tools and/or systems of work?: (if yes give details)
Action taken to make the situation/environment safe: (e.g. report premises defects to Line Manager)
Name: / Designation:
Contact Details:

Thank you for helping Aberness Care provide a supportive, safe and healthy work environment by reporting this incident. Please forward this form to your line manager, who will complete a risk assessment and ensure that an investigation is carried out if required.

ACTION TAKEN / Receiving Adviser: / Date:
RIDDOR reportable? / Yes / No / RIDDOR ref: / Date:
Type of incident: / First aid / Work related accident / Work related ill health / Work related violence / Road traffic
accident / Non injury incident
Investigated by: / Agency Support Services Not required
Copy of incident report passed to: / Date:
Report passed to OH? / Yes / No / Date: / Report passed to Insurance Company? / Yes / No
Date investigation report returned: / Witness statements / photos / RIDDOR attached? / Yes / No