The Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995
Report of an injury or dangerous occurrence
Filling in this form
This form must be filled in by an employer or other responsible person.
Part A
About You
What is your full name?
1
What is your job title?
2
What is your telephone number?
3
About your organisation
What is the name of your organisation?
4
What is its address and postcode?
5
What type of work does the organisation do?
6
Part B
About the incident
On what date did the incident happen?
1
At what time did the incident happen? (Please use the 24-hour clock e.g. 0600)
2
Did the incident happen at the above address?
3
Yes
Go to question 4
No
Where did the incident happen?
elsewhere in your organisation - give the name, address and postcode
at someone else's premises - give the name, address and postcode
in a public place - give details of where it happened
If you do not know the postcode, what is the name of the local authority?
In which department, or where on the premises, did the incident happen?
4
Part C
About the injured person
If you are reporting a dangerous occurrence, go to part F. If more than one person was injured in the same incident, please attach the details asked for in part C and part D for each injured person.
What is their full name?
1
What is their home address and postcode?
2
What is their home phone number?
3
How old are they?
4
Are they
5
male?
female?
What is their job title?
6
Was the injured person (tick only one box)
7
one of your employees?
on a training scheme? Give details:
on work experience?
employed by someone else? Give details of the employer:
self-employed and at work?
a member of the public?
Part D
About the injury
What was the injury (e.g. fracture, laceration)?
1
What part of the body was injured?
2
Was the injury (tick the one box that applies)
3
a fatality?
a major injury or condition? (see accompanying notes)
an injury to an employee or self-employed person which prevented them doing their normal work for more than 3 days
an injury to a member of the public which meant they had to be taken from the scene of the accident to a hospital for treatment?
Did the injured person (tick all the boxes that apply)
4
become unconscious?
need resuscitation?
remain in hospital for more than 24 hours?
none of the above
Part E
About the kind of accident
Please tick the one box that best describes what happened, then go to part G.
Contact with moving machinery or material being machined
Hit by a moving, flying or falling object
Hit by a moving vehicle
Hit something fixed or stationary
Injured while handling, lifing or carrying
Slipped, tripped or fell on the same level
Fell from a height
How high was the fall?
Trapped by something collapsing
Drowned or asphyxiated
Exposed to, or in contact with, a harmful substance
Exposed to fire
Exposed to an explosion
Contact with electricity or an electrical discharge
Injured by an animal
Physically assaulted by a person
Another kind of accident (describe it in Part G)
metres
Part F
Dangerous occurences
Enter the number of the dangerous occurence you are reporting. (The numbers are given in the Regulations and in the notes which accompany this form)
Part G
Describing what happened
Give as much detail as you can. For instance
the name of any substance involved the name and type of any machine involved the events that led to the incident the part played by any people
If it was a personal injury, give details of what the person was doing. Describe any action that has since been taken to prevent a similar incident. Use a separate piece of paper if you need to.
Part H
Your signature
Signature
Date
Where to send the form
Please send it to the Enforcing Authority for the place where it happened. If you do not know the Enforcing Authority, send it to the nearest HSE office.