Document Revised to Include New Myrisks Links July 2013

BBC ACCIDENT/INCIDENT NOTIFICATION FORM (accessible version)

BBC Health and Safety arrangements require all accidents and incidents to be reported by the Injured Person or by the person in charge of the activity, as soon after the incident as possible and it must be a true and accurate statement of what happened.
PLEASE RECORD THE ACCIDENT OR INCIDENT ON MYRISKS: myRisks Tools If you are unable to access myRisks please contact the safety advice line: (+44 (0) 370 411) x0464 or e-mail:
If you are unable to record the incident on myRisks this form can be used to make a temporary record the details of the accident/incident. Please complete all sections and report it on myRisks within 1 week. This document can be read by accessible screen readers such as JAWS. Use the mouse or TAB key to move from one cell to the next in the table. For guidance see: Reporting Accidents & Incidents at the BBC. 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.
Privacy Notices
Personal information collected during incident reporting and investigation will be used to fulfil the BBC’s obligations under Health and Safety policy and legislation. It will be retained by the BBC for up to 6 years after the incident. It may be shared with other organisations, including our agents and contractors, with whom the risk or the control of risk is shared. You have the right to confirm that any information held about you is correct.
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. Personal details can only be provided with the consent of the person to whom they relate.
INCIDENT DATE / INCIDENT TIME / REPORT DATE / REPORT TIME
INCIDENT OWNERSHIP [Which department does the injured person (IP) work for OR which department was in charge of the activity?]
Division / Department / Business unit / Programme/Event (if applicable)
INCIDENT DESCRIPTION
Give as much detail as you can, e.g. name any substance or equipment involved, events leading up to the accident or incident including what was happening at the time, the part played by any people, what the injured person (if applicable) was doing at the time of the Incident and if the injured person has been off work as a result of the incident. Please include any external organisations already contacted (for example, Police, Fire, Ambulance, HSE, Environment Agency)
Note: For the purposes of data protection, names of individuals should not be used in this section - please use IP for injured person, or the terms 1st / 2nd on scene etc and witness, as appropriate.
Did it occur on a BBC Site / Region / Location / Area
YES NO
INCIDENT LOCATION [Please give exact details of the location at which the incident took place, including details of site management/ownership/contact details if not BBC premises:]
HOW MANY PEOPLE WERE INVOLVED? Add details for 2nd / 3rd person at end of form / 0123more than 3
PERSON INVOLVED: [IF MORE THAN ONE PERSON INVOLVED ADD DETAILS IN SECTIONS AT END OF FORM]
Serious accidents and incidents, which include those resulting in broken bones, days away from work, any hospital treatment or involving the emergency services, must be reported to BBC Safety by phone or email as soon as possible. They will also be able to help you decide what to do next.
Is consent given for details of their involvement in this incident being passed to their union representative? / YES NO
Category of person: / Employee Contractor Freelance Artist/Contributor Member of Public Other
Nature of involvement: / Injured Person/victim Other involvement Witness First on scene
Title: / First Name: / Last Name: / Staff No:
Contact Tel No: / Email address:
Contact address (if non-BBC staff): / Home address: (of injured person)
OTHER WORK DETAILS
Occupation / Team Leader or Supervisor / Department Head
DETAILS OF INJURY AND RESULTING ABSENCE FROM WORK:
Nature of Injury: / Body Location: [arm, leg etc] / Body Sub Category: [toe, finger etc] / Body Side [left, right, both]
Was treatment given, if yes where was it given? / No treatment given Treatment offered but refused at scene
at local first aid point at Occupational Health at local GP surgery at hospital
Date of treatment: / Time of treatment:
Nature of treatment,
Provided by:
Became unconscious? / YES NO / Required resuscitation? / YES NO
In hospital >24hrs? ;Yes / YES NO
After treatment: / Returned to Work Referred to hospital Sent or taken to hospital
Referred to dentist Referred to own GP Sent or taken home
Mode of transport (if applicable): / By organisation vehicle By hospital vehicle By private vehicle by taxi
by ambulance by air ambulance By other means unknown
Not applicable
Next of-kin notified? / YES NO
HOURS OF WORK ON THE DAY OF THE INCIDENT
Start Time: / End Time
Other relevant information [Please record further details as appropriate about this person]
DAMAGE DETAILS
Item Damaged:
Details:
OTHER INFORMATION AND CORRECTIVE ACTION [What immediate action has been taken to prevent a recurrence and by whom?]
Has the injured person been referred to BBC Occupational Health for a return to work fitness assessment? / YES NO
INCIDENT REPORTED BY
NAME
DATE
Please save this form and email it to your line manager, having completed details about 2nd / 3rd persons involved below, if appropriate.
Details of other persons involved.
2nd PERSON INVOLVED: [ADD DETAILS HERE]
Is consent given for details of their involvement in this incident being passed to their union representative? / YES NO
Category of person: / Employee Contractor Freelance Artist/Contributor Member of Public Other
Nature of involvement: / Injured Person/victim Other involvement Witness First on scene
Title: / First Name: / Last Name: / Staff No:
Contact Tel No: / Email address:
Contact address (if non-BBC staff): / Home address: (of injured person)
OTHER WORK DETAILS
Occupation / Team Leader or Supervisor / Department Head
DETAILS OF INJURY AND RESULTING ABSENCE FROM WORK:
Nature of Injury: / Body Location: [arm, leg etc] / Body Sub Category: [toe, finger etc] / Body Side [left, right, both]
Was treatment given, if yes where was it given? / No treatment given Treatment offered but refused at scene
at local first aid point at Occupational Health at local GP surgery at hospital
Date of treatment: / Time of treatment:
Nature of treatment,
Provided by:
Became unconscious? / YES NO / Required resuscitation? / YES NO
In hospital >24hrs? ;Yes / YES NO
After treatment: / Returned to Work Referred to hospital Sent or taken to hospital
Referred to dentist Referred to own GP Sent or taken home
Mode of transport (if applicable): / By organisation vehicle By hospital vehicle By private vehicle by taxi
by ambulance by air ambulance By other means unknown
Not applicable
Next of-kin notified? / YES NO
HOURS OF WORK ON THE DAY OF THE INCIDENT
Start Time: / End Time
Other relevant information [Please record further details as appropriate about this person]
3rd PERSON INVOLVED: [ADD DETAILS HERE]
Is consent given for details of their involvement in this incident being passed to their union representative? / YES NO
Category of person: / Employee Contractor Freelance Artist/Contributor Member of Public Other
Nature of involvement: / Injured Person/victim Other involvement Witness First on scene
Title: / First Name: / Last Name: / Staff No:
Contact Tel No: / Email address:
Contact address (if non-BBC staff): / Home address: (of injured person)
OTHER WORK DETAILS
Occupation / Team Leader or Supervisor / Department Head
DETAILS OF INJURY AND RESULTING ABSENCE FROM WORK:
Nature of Injury: / Body Location: [arm, leg etc] / Body Sub Category: [toe, finger etc] / Body Side [left, right, both]
Was treatment given, if yes where was it given? / No treatment given Treatment offered but refused at scene
at local first aid point at Occupational Health at local GP surgery at hospital
Date of treatment: / Time of treatment:
Nature of treatment,
Provided by:
Became unconscious? / YES NO / Required resuscitation? / YES NO
In hospital >24hrs? ;Yes / YES NO
After treatment: / Returned to Work Referred to hospital Sent or taken to hospital
Referred to dentist Referred to own GP Sent or taken home
Mode of transport (if applicable): / By organisation vehicle By hospital vehicle By private vehicle by taxi
by ambulance by air ambulance By other means unknown
Not applicable
Next of-kin notified? / YES NO
HOURS OF WORK ON THE DAY OF THE INCIDENT
Start Time: / End Time
Other relevant information [Please record further details as appropriate about this person]
Completed

If more than three persons are involved please use a second form to record the information about the additional persons and submit this too. When the information is entered into the electronic Incident report on myRisks there are tabs to enter records about everyone involved.

Document revised to include new myRisks links July 2013.

If you need help completing this form, please contact: Safety Advice Line (0370 411) 0464

Safety-Accident_Report_Form-Accessible.doc 4 of 4 30/07/2013