::Incident Reporting:: Create New Incident

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Job Title:

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Injury Report > New Report

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I am reporting a work related:

Incident Report Manager:

Start Date:

Start Time:

Are you the person who had the accident?

Yes

Have the relevant line / area manager’s been directly notiﬁed?

Yes

Name of Manager / Supervisor?

Does the person involved in the incident work in your organisation?

Why were they there?

What is your connection to the injured party?

Please specify

Please Enter Your Details Name:

Email:

Please provide details of the person who had the accident.

Full Name

Job Title

Address 1

Address 2

Address 3

Post/Zip Code

Tel

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Please specify location?

Was the incident related to the work being done?

Yes

How was the incident related to work?

What happened?

What activities were being carried out at the time?
Were relevant safety precautions in place and operational?
What directly caused the injury or illness?
What were the environmental conditions at the time of the incident?

Was any equipment or substance involved?

Yes

Please specify if ‘yes’?

Please add any photos related to the accident / incident.
You can add photos at any point during the reporting process by clicking on the 'Add Photo' button located at the bottom left side of the screen.

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Were there any witnesses?

Yes

Complete details for each witness.

Full Name*

Job Title

Address 1

Address 2

Address 3

Post/Zip Code

Tel

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Witness List

What do you think could have been done to prevent this incident?

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ABOUT THE INJURY OR NEAR-MISS

Complete this section to specify what the injury is & which part of the body are injured.

How serious is the injury? If it was a near-miss, how could somebody have been hurt?

Amputation
Asphyxia (oxygen deprivation)
Back Pain
Bruising
Burns
Concussion
Crushing Injury
Dislocation
Electric Shock
Eye Injury / Loss of Sight
Fractures
Hand arm vibration syndrome (HAVS)
Hand or finger injury
Head or facial injury
Hearing loss or damage
Laceration / Cut
Poisoning
Sprain / Strain
Other

Which part(s) of the body is injured?

Ankle

Other body part

How serious was the injury?

Any further comments about the injury?

Specify other injury?

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Any First Aid given?

Yes

Who gave the first aid?

What was the next course of action for the person/s affected?

How much time was taken off work? (not including day of injury)

Please specify number of days:

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ill Health

Complete this section to specify what the ill heath is.

You skip this section by clicking ‘Next’.

Allergic Reaction
Anxiety
Asbestosis
Asthma
Chest Pain
Dehydration
Fainting
Fatigue
Flu or fever
Headache or migraine
Heat exhaustion
Hypothermia
Nausea
Shock
Shortness of Breath
Sore Throat
Stress
Vomiting
Other

Any other comments about the ill-health?

Specify Other ill-Health?

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ABOUT THE INJURY OR NEAR-MISS

Complete this section to specify what the injury is & which part of the body are injured.

How serious is the injury? If it was a near-miss, how could somebody have been hurt?

Amputation
Asphyxia (oxygen deprivation)
Back Pain
Bruising
Burns
Concussion
Crushing Injury
Dislocation
Electric Shock
Eye Injury / Loss of Sight
Fractures
Hand arm vibration syndrome (HAVS)
Hand or finger injury
Head or facial injury
Hearing loss or damage
Illness
Laceration / Cut
Poisoning
Sprain / Strain
Other

How serious was the injury?

Any further comments about the injury?

Specify other injury?

Add Photo 0 Image file(s)

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You’re Nearly There

You can now add your company details and logo to your report. Simply register for Free and your report will be instantly downloaded. You can then return to your free dashboard to access your report, anywhere, anytime.

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I consent to my personal information being shared.

We, Safety Apps Ltd, will store any incident reports that you submit on behalf of the relevant account holder. In relation to any personal data in an incident report, we act as a processor on behalf of the account holder; the account holder acts as controller. Using our software, the account holder may share that personal data with others. To find out more about how the account holder will handle personal data, you should read the privacy notice of the account holder.

Photos

If you are adding images we recommend adding photos of the location where the incident/accident took place. Please avoid adding photos of injuries or people.

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Body Part(s)

Ankle
Back
Ear
Eye
Finger or Fingers
Foot
Hand
Head
Lower Limb
Neck
Other parts of Face
Toe
Torso
Upper Limb
Wrist
Other

Images

Job Title

Job Title: