"Accident/Incident Report Form"

ADVERTISEMENT
ACCIDENT / INCIDENT REPORT FORM
(This form is to be completed for all volunteers, service users and visitor accidents /incidents)
Please fill in the churches accident form separately to this form and hand it into the office.
All accidents/incidents to be reported. Wittiness statements to be taken/written where appropriate.
Management is required to complete Section III, review the report for completeness and accuracy, sign and log this
report in the accident/incident log book within 24 hours of the accident/incident. Note: the report (and pictures if
any) should then be filed together in a safe and secure location. Any copies of this report and any other related
materials in conjunction with this report cannot be obtained without the authorization of management.
Preserve evidence.
Do a body map where appropriate.
Record all information as soon as possible.
Record what the circumstances in which the accident/incident came
Use black pen.
about.
Keep writing clear and legible.
Note the setting and anyone else who was there at the time, and
Do not use jargon or abbreviate.
record this using their own words/phrases.
Do not record your own opinion if you are filling the form in on behalf of
Do not touch anything that may be evidence.
another person.
If the incident was witnessed then the witness needs to do a
Use fact and the individuals own words, expressions, appearance, behaviour
witness statement and write down exactly what was seen.
and views.
SECTION I
PLEASE PRINT OR TYPE ALL INFORMATION
Name:
TELEPHONE NUMBER:
Address:
Mobile phone number:
Date of birth
Age:
(why were you visiting?)
Postcode:
Volunteer
Service user
Trustee
Visitor
ACCIDENT / INCIDENT REPORT FORM
(This form is to be completed for all volunteers, service users and visitor accidents /incidents)
Please fill in the churches accident form separately to this form and hand it into the office.
All accidents/incidents to be reported. Wittiness statements to be taken/written where appropriate.
Management is required to complete Section III, review the report for completeness and accuracy, sign and log this
report in the accident/incident log book within 24 hours of the accident/incident. Note: the report (and pictures if
any) should then be filed together in a safe and secure location. Any copies of this report and any other related
materials in conjunction with this report cannot be obtained without the authorization of management.
Preserve evidence.
Do a body map where appropriate.
Record all information as soon as possible.
Record what the circumstances in which the accident/incident came
Use black pen.
about.
Keep writing clear and legible.
Note the setting and anyone else who was there at the time, and
Do not use jargon or abbreviate.
record this using their own words/phrases.
Do not record your own opinion if you are filling the form in on behalf of
Do not touch anything that may be evidence.
another person.
If the incident was witnessed then the witness needs to do a
Use fact and the individuals own words, expressions, appearance, behaviour
witness statement and write down exactly what was seen.
and views.
SECTION I
PLEASE PRINT OR TYPE ALL INFORMATION
Name:
TELEPHONE NUMBER:
Address:
Mobile phone number:
Date of birth
Age:
(why were you visiting?)
Postcode:
Volunteer
Service user
Trustee
Visitor
SECTION II ACCIDENT DATA
Physical altercation
Accident/Injury
Verbal
Other: Please specify
NATURE OF
Confrontation
INCIDENT:
Damage to
Theft/Burglary
property
DATE of Accident/Incident:
Time of Accident/Incident:
am
pm
Where did the Accident/Incident
Occurred? Address/location:
Specific Location of Accident/Incident
Example: Bathroom, car park:
Briefly explain what happened: Include mood of persons involeved and what was happening before the incident. If there was an injury,
what happened to cause this injury or illness (3) what was the injury or illness (i.e., state the part of body affected and how it was
affected) Use additional paper if needed.
What action was taken: Check all actions taken. If more than one, indicate which occurred 1st, 2nd, etc.
First Aid – administered by:
Medical help sought (What and where) :
Sent Home
Other agencies informed:
Social services
Police
RIDDOR
Continued Activity (no action taken)
Other: Please specify:
Other: please specify:
Names and contact numbers of witnesses:
Person Completing the Report:
Signed:
Print name:
Date:
Reviewed by Risk Manager:
Signed:
Print name:
Date:
Return form same day (or within 24 hours) of accidents/incident for employee, patron, or visitor to the Venues Management
Department.
Accident/Incident Report Form
SECTION III
MANAGEMENT/SUPERVISOR REPORT ON THE ACCIDENT/INCIDENT
What action has been taken to prevent such an accident/incident from recurring? Include specific details on how it was
(take photos of environment following an incident):
mediated, how the incident can be avoided in the future.
Management/Supervisor’s Account of Incident which supplements and/or clarifies information provided by injured party: (if an
injury, (1) explain activities occurring when injury or illness occurred and what tools, machinery, chemicals, were involved, (2) what
happened to cause this injury or illness (3) what was the injury or illness (i.e., state the part of body affected and how it was
affected)
Section III Completed by: _______________________________________________________________
Signature:
Date:
SECTION IV-
FOR INVESTIGATION/REVIEW ONLY - DO NOT WRITE BELOW THIS LINE:
Investigation Comments: Photos are highly recommended immediately following an incident, if at all possible.
Required Action:
Section IV Completed by: _______________________________________________________________
Signature
Date
Date sent to Board of trustees: ________________
ADVERTISEMENT

Download "Accident/Incident Report Form"

471 times
Rate
(4.7 / 5) 24 votes