New Incident Report

Reported By*

Category* Select Category... Accident Ill Health Property Damage Violence & Abuse Incidents/Near Miss

Severity N/A 1 - Critical 2 - Major 3 - Moderate 4 - Minor

Record Injured Persons details? No Yes

About the injured person

Name

Job Title

Address 1

Address 2

Address 3

Town

County

Post code

Gender Male Female Other

Age

Status Employee of company Employed by someone else On a Training Scheme On work experience Self employed at work Member of the Public

Has this person given consent for their employer to disclose their personal information and details of the accident to safety representatives for them to carry out safety functions required by law? No Yes

Injured Area

	Abdomen		Ankle		Arm
	Back		Chest		Ear
	Elbow		Eye		Face
	Fingers		Foot		Groin
	Hand		Head		Hip
	Knee		Leg		Mouth
	Neck		Nose		Shoulder
	Toes		Wrist

Incident date*

Incident time*

Area* Other Frederick Bremer School

Location*

Weather conditions (if applicable)

Incident type* Other Aggression Allergic reaction / medical condition/ Pre-existing Health or Medical Condition Assault / Physical abuse Contact with electricity Contact with fixed object Contact with hot surfaces/liquids/naked flame Contact with moving machinery / equipment Contact with sharp object Drowning or asphyxiation Drug/Alcohol Influenced Explosion Exposure to / contact with hazardous substance Fall from Height Fire Handling / lifting / carrying injury Hit by moving / flying / falling object Hit by moving vehicle Hit by/Strike against something fixed / stationary injured by animal / insect bite Other/Unknown PE Physical assault by service user Public Nuisance Security / Theft incident Self-harm Slip, Trip, Fall same level Theft / Break in Trapped by something collapsing/overturning/moving Vandalism Vehicle related damage Vehicle related incident Verbal abuse- face to face/email/text

Description of Incident*

Action taken at the time*

Root cause category* Other Equipment – correct maintenance and appropriate use / design / PPE / inspection and monitoring Management and Supervision- e.g. are safe practices reinforced and unsafe practices confronted/ Lack of supervision/ Behaviour of people involved/ Horseplay. Medical / Health Condition – e.g. Injured person or third-party ill health caused or contributed to the incident. People - e.g. Fatigue /Distractions/ Inattentive/carelessness/ poor judgment/ attitude (work more important than safety) / Pressure of work Procedure - Are local policies/procedures and risk assessments available? Do these need to be improved? Were safety procedures complied with. Safeguarding- e.g. vulnerable person exposed to risk. Security- e.g. Loss/theft of item caused by inadequate security protocol. Skills - Have staff received appropriate information, training, and instruction. Surroundings (place, environment) – e.g. was the lighting adequate, flooring in good condition, adverse weather conditions present, housekeeping.

Details of root cause of the incident (if known)

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