ADULT ACCIDENT/NEAR MISS/ASSAULT INCIDENT REPORT
DETAILS OF INJURED PERSON Academy:
Employee: Y / N
Date of Incident:
Agency:
Time of Incident:
Y/N
Full Address of Injured Person:
Postcode
Tel No.
:
Mr / Mrs / Miss / Dr
First Name:
Other………..
Last Name:
Date of Birth
Age
24hr
Male/Female*
STATUS OF INJURED PERSON Employee
Agency
Volunteer
Member of the Public
Work Placement
Other
…………………………..
Teacher/Academic Support/Non-Academic Support
Location
…………………………………………………………………
…………………………………………………………………
Full Time / Part Time / Job Share*
Occupation (in full) ………………………………………….
ACCIDENT/INCIDENT DETAILS Please note that if the answer is yes to any of the following 3 questions, this report must be faxed or delivered by hand to the Federation within 24 hours of the incident occurring. WAS THE INJURED PERSON: Taken home?
Yes/No*
WAS THIS INCIDENT:
Taken Directly to Hospital? AN ACCIDENT
Yes/No*
Absent from the Academy/work Yes/No*
A NEAR MISS INCIDENT
AN ASSAULT
LOCATION DETAILS Boiler House
Staffroom
Dining Room
Toilets
Kitchen
Classroom/Lab/Prep Lab
Gym/Sports Hall/AWP/Playing Fields
Office/Staffroom
Stores
Roof
Workshop
Stairway
Entry/private Road
Workshop
Grounds
Swimming Pool
Scaffold/Access Area
Other………………………………………………………
EXPLAIN WHAT HAPPENED LEADING UP TO AND INCLUDING THE INCIDENT:-
INJURY DETAILS NATURE OF INJURY:Fracture
LOCATION OF INJURY:-
MARK LOCATION
Description:-
Strain/Sprain Abrasion Laceration Burn Eye Injury Crush Other Details, if required………………………………….
Please turn over ….
ADULT ACCIDENT/NEAR MISS/ASSAULT INCIDENT REPORT
IS THERE ANY PRE-EXISTING INJURY OR MEDICAL CONDITION THAT MAY HAVE CONTRIBUTED/RELEVANT TO THE INCIDENT? Yes/No/Uncertain* If yes, please give details……………………………………………………………………………………………………
DETAILS OF ANY FIRST AID TREATMENT GIVEN ………………………………………………………………………... ……………………………………………………………………………………………………………………………………… Following the accident/incident, what, if any remedial action has been taken to prevent a recurrence (write ‘none’ if no action taken)?
Please note that if the answer is yes to any of the following 4 questions, this report must be faxed or delivered by hand to the Federation within 24 hours of the incident occurring. WAS THE INCIDENT CAUSED BY: Equipment Design
Yes/No*
Failure of Equipment?
Yes/No*
Premises Problems?
Yes/No*
H&S Systems Failure?
Yes/No*
Data Protection Act. The information provided on this form will be used in pursuance of the Federation’s prevention of accidents programme. Where necessary, the information will be shared with the Health and Safety Executive and the Federation’s insurers. [Manager/Supervisor/Principal/Head of Learning Area]
Signed (Responsible Person): ………………………………………………………………… Date: ………………………………………. Print Name:………………………………………………………………………………………. Tel No: …………………………………….. Job Title: ……………………………………………………………………………………………
OFFICE USE ONLY HSE Incident Number:
Date:
F2508?
Investigation Required? Yes/No*
Yes/No* Details:
INSURANCE AND RISK DEPARTMENT INFORMED?
PHOTOGRAPHS TAKEN?
Yes/No*
Yes/No*
ELECTRONIC REFERENCES:
Federation Health & Safety Coordinator SIGNED………………………………………..
Date Form Received ………………………………………..
DATE ………………………………………….
By Whom ……………………………………….……………. The Ridings’ Federation of Academies Federation House, 17 High Street Winterbourne Bristol BS36 1JJ Tel. 01454 252041
FAX (Accidents/Incidents & Assaults): 01454 252060 Form AA/122009/HS/v1.1/LMH