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🏢

What is the company name?

Full legal name of the company where the accident occurred

📍

What is the site/location?

Specific site or office where the accident occurred

👤

Injured person's full name?

Full legal name of the injured person

🎂

Date of birth?

Injured person's date of birth

💼

Job title?

Position at the time of the accident

📝

Employment status?

Status of the injured person

👷
Employee
🔨
Contractor
🚶
Visitor
🧑‍🤝‍🧑
Member of Public
🏗️

Department?

Department or team of the injured person

📅

Length of service?

How long have they worked for the company?

🗓️

Date of accident?

Exact date when the accident occurred

🕐

Time of accident?

As accurately as possible

📌

Exact location of accident?

Building, floor, department, aisle — be specific

📋

What happened?

Detailed chronological account of the incident

⚙️

Activity at time of accident?

What was the person doing when it happened?

👥

Anyone else involved?

Names and details of other people directly involved

🩹

Type(s) of injury?

Select all that apply

✂️
Cut/Laceration
🟣
Bruise/Contusion
🦴
Fracture
💢
Sprain/Strain
🔥
Burn/Scald
⚠️
Crush Injury
🏥
Amputation
🧠
Concussion
👁️
Eye Injury
🫁
Back Injury
Other
🫀

Body part(s) affected?

Select all that apply

👤
Head
😮
Face
👁️
Eye
🦒
Neck
💪
Shoulder
💪
Arm
Hand
🫁
Chest/Back
🫃
Abdomen
🦵
Hip/Pelvis
🦵
Leg
🦵
Knee
🦶
Foot/Ankle
⚠️
Multiple Areas
⚕️

Was first aid given?

Was first aid administered after the accident?

Yes
No
🧑‍⚕️

First aid given by?

Name and qualifications of person who gave first aid

💊

Treatment provided?

Describe the specific first aid treatment given

🏥

Taken to hospital?

Did the injured person attend hospital?

Yes
No
🏨

Hospital name?

Name of hospital or medical facility attended

🚑

Ambulance called?

Were emergency services called?

Yes
No
📋

Is this RIDDOR reportable?

Death, specified injury, over-7-day absence, non-worker to hospital, dangerous occurrence or occupational disease

Yes
No
Unsure
📌

Reason for RIDDOR classification?

Select all applicable criteria

Death
🏥
Specified Injury
📅
Over-7-day Incapacitation
🚑
Non-worker to Hospital
⚠️
Dangerous Occurrence
🦠
Occupational Disease
📨

Date reported to HSE?

RIDDOR requires notification within 15 days

🔢

HSE reference number?

Reference assigned by HSE when reported

✍️

Reported to HSE by?

Name and title of person who reported to HSE

👁️

Any witnesses?

Did anyone else see the accident occur?

Yes
No
🧑

Witness 1 name?

Full name of first witness

📞

Witness 1 contact details?

Phone number or email address

💬

Witness 1 statement?

What did they see?

🧑

Witness 2 name?

Full name of second witness (if any)

📞

Witness 2 contact details?

Phone number or email address

💬

Witness 2 statement?

What did they see?

🔍

Immediate cause?

The direct cause of the injury

🎯

Underlying cause?

Root causes beyond the immediate trigger

🛡️

Could it have been prevented?

How could this accident have been prevented?

✔️

Actions to prevent recurrence?

Immediate corrective actions already taken

📝

Corrective action required?

Specific action needed to prevent recurrence

👤

Responsible person?

Who is accountable for completing this action?

📅

Target completion date?

Deadline for completing the corrective action

Actual completion date?

When was the action completed? (Leave blank if not yet done)

🔏

Verified by?

Manager who verified the action was completed

🏖️

Time off work?

Did the injured person take time off as a result?

Yes
No
🚪

Date they left work?

When absence began

🚀

Date returned to work?

When did they return to full duties?

📊

Total days absent?

Over 7 days is RIDDOR reportable

✍️

Injured person signature?

Type their name as acknowledgement

📅

Injured person sign-off date?

Date when injured person acknowledged the report

👔

Reporting manager signature?

Type manager's name as signature

📅

Manager sign-off date?

Date manager reviewed and signed off

🦺

H&S manager signature?

Health & Safety manager review signature

📅

H&S manager review date?

Date H&S manager completed their review

🏁

Investigation completed?

Is the full investigation complete?

Yes
No — Further investigation required

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