RIDDOX by SteSec ltd.

Incident Form

This form is to be used to report accidents that have led to injuries or incidents or dangerous occurrences that while not causing injuries had the potential to cause them e.g. near misses such as failures of equipment, items falling from height.

Site Location

Date of accident / incident / dangerous occurrence

Time of accident / incident / dangerous occurrence

Location of accident / incident / dangerous occurrence

Room Name / Number

Name of injured person or witness of incident or dangerous occurrence

Name of Head of Department

Extension Number

Approximate Age Of Injured Person

16 - 20 21 - 30 31 - 40 41 - 50 51 - 60 61 - 65 Over 65

Student's ID / Staff ID

Type

Institute / Department

Normal or term time location / address of injured person

Contact Details Of Injured Person

Names And Contact Details Of Witnesses Present

Type Of Incident

Nature Of Incident

Type Of Illness

Type of injury

Anatomical Location Of The Injury (if required)

First aid given?

No Yes

If Yes, Give Details

Taken to Emergency Department (A&E)?

No Yes

If Yes, Give Details

Was there a damage to vehicle, equipment or property?

No Yes

If Yes, Give Details

PPE Personal Protection Equipment Worn

No Yes

If Yes, Give Details

Chemicals Involved

No Yes

Contributory and Aggravating factors

Dark Artificial Light No Lightning Snow Fog Wet Other

Other Contributory and Aggravating factors

Activity during which the event happened

Details of accident or incident (if applicable)

Emergency services attended

Police Ambulance Fire & Rescue

What happened to the injured/ill person?

Will the employee be absent from work for more than 3 days?

No Yes

Will the employee be absent from work for more than 7 days?

No Yes

Statement

Attachments

Person who filled this form

First Name

Last Name

Phone

All of the above are true and accurate record of the incident/accident.