ADULT ACCIDENT/NEAR MISS/ASSAULT INCIDENT REPORT

DETAILS OF INJURED PERSON

Academy: Employee: Y / N Date of Incident:

Agency: Y / N Time of Incident: : 24hr

Full Address of Injured Person:

Postcode Tel No.

Mr / Mrs / Miss / Dr

Other………..

First Name:

Last Name:

Date of Birth Age Male/Female*

STATUS OF INJURED PERSON

Employee Agency Volunteer Member of the Public Work Placement Other …………………………..

Teacher/Academic Support/Non-Academic Support

…………………………………………………………………

Full Time / Part Time / Job Share*

Location

…………………………………………………………………

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* Taken Directly to Hospital? Yes/No* Absent from the Academy/work Yes/No*

WAS THIS INCIDENT: AN ACCIDENT A NEAR MISS INCIDENT AN ASSAULT

LOCATION DETAILS

Boiler House

Dining Room

Kitchen

Gym/Sports Hall/AWP/Playing Fields

Stores

Workshop

Entry/private Road

Grounds

Scaffold/Access Area

Staffroom

Toilets

Classroom/Lab/Prep Lab

Office/Staffroom

Roof

Stairway

Workshop

Swimming Pool

Other………………………………………………………

EXPLAIN WHAT HAPPENED LEADING UP TO AND INCLUDING THE INCIDENT:-

INJURY DETAILS

NATURE OF INJURY:-

Fracture

Strain/Sprain

Abrasion

Laceration

Burn

Eye Injury

Crush

Other Details, if required………………………………….

LOCATION OF INJURY:-

Description:-

MARK LOCATION

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?

Yes/No*

Investigation Required? Yes/No*

Details:

INSURANCE AND RISK DEPARTMENT INFORMED?

Yes/No*

PHOTOGRAPHS TAKEN?

Yes/No*

ELECTRONIC REFERENCES:

Federation Health & Safety Coordinator

SIGNED………………………………………..

DATE ………………………………………….

Date Form Received ………………………………………..

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