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