HEALTH AND SAFETY INCIDENT REPORTING
Must ensure all parts of the incident
form have been fully and accurately Ensure that the incident is reported as
completed. soon as is reasonably practical after the
incident has taken place. Complete all the
relevant sections of the Essex County
Council Incident Form. If you are unable to
do this someone may complete the form
Must ensure that any statutory for you.
reporting under the HSE Reporting of
Injuries, Diseases and Dangerous
Occurrences Regulations (RIDDOR) is
carried out. Data Protection: Personal data on this
form will be held on computer files. The
information may be shared with other
authorised persons for accident prevention
Carry out an investigation into the
purposes or as evidence in the event of
cause of the incident.
civil or criminal action being taken against
the County Council.
Data Protection: Managers must treat
information on the accident form as
confidential and only disclose it to
those who need to know. It must be Where to send this form: Employees
forwarded in a sealed envelope must pass the form to their Manager when
marked "Confidential" and any copies they have completed the relevant sections.
stored securely. Your manager will investigate the incident
and pass a copy of the form to the
Council’s Health and Safety Service.
Report incident using the Online Non-employees/service users should
Incident Reporting Form within 10 ensure the manager of the establishment
days. Copies of RIDDOR reports (i.e. or their appointed person receives the
the F2508 for accidents and dangerous form.
occurrences or F2508a for diseases) and
any statements/additional information
must be included with the form.
For staff: A signed copy of the form Aided Schools and other establishments who buy a
should also be retained on the premises Health and Safety Service from Essex County Council
for 3 years. may use this form to record incidents but must retain
completed forms in the establishment.
For Pupils: A copy of the form should be
kept until 3 years after a child turns 18.
Revised: August 2012
SCHOOLS HEALTH AND SAFETY INCIDENT FORM
DETAILS (Please write clearly and legibly, giving as much relevant information as possible. Do not use abbreviations)
Service Details: (i.e. Address of reporting establishment/team) (Please print in full)
Name of person completing form:
ABOUT THE INCIDENT
Type of incident (Please circle one)
Accident Work related ill-health Violence (physical or verbal) Non-injury incident (near miss)
Date of incident: Time of incident: a.m. / p.m.
Date Incident reported: Time incident reported: a.m. / p.m.
Where did incident occur? (State location i.e. playground/classroom and full address if different from above)
How did the incident happen?
Circle one that best describes the cause of the incident:
Bite Chemical Exposure Collapse of Structure Contact Electricity Contact Heat Fall Height Falling Object Fire
Hazardous Substance Infectious Agent Machinery in Operation Manual Handling Moving Vehicle Psychological
Road Traffic Accident Slips, Trips and Falls Sport/Physical Training Struck Against Struck By Violence
Circle one that best describes the injury location:
Abdomen Arm Back Chest Fingers/Toes Foot/Ankle Hair Pulling Hand/Wrist Head Hips Internal Leg
Multiple Non-injury Incident Not Applicable Shoulder/Neck
Circle one that best describes the nature of harm:
Amputation Bruise/Graze Burn Concussion Cut Death Dental Dislocation Electric Shock Eye Injury
Fracture Laceration Muscular Penetration/Puncture Shock Stress
Was the injured person taken directly to hospital? Yes / No
RIDDOR: Guidance is available on the HSE website www.hse.gov.uk/RIDDOR
Was the incident reportable under RIDDOR? Yes / No
If Yes please circle the appropriate description to indicate type of incident:
Fatality Major injury to employee Over 7 day injury to an employee Non-employee taken to hospital
Reportable disease (ill health) Reportable dangerous occurrence
Details of Person affected by the incident
Revised: August 2012
Name of Person affected by the incident: (Please print)
Is affected person an Essex County Council employee? Yes / No
If Yes circle one of the following that best describes their occupation:
Administrator/Clerical Care Assistant Caretaker Cleaner Community Support Facilitator Cook Driver
Grounds Maintenance Home Care Learning Support Assistant Librarian Midday Assistant Professional
Registered Manager Schools Crossing Social Worker Support Team Manager Support Worker Teacher
Transport Engineer Tutor Youth Worker
INCIDENT INVESTIGATION: Guidance is available from the Health and Safety pages of the intranet.
Circle one of the following that best describes any action that has been taken following the incident:
Additional Supervision Training Modifying Existing Systems of Work Repair to Premises Review Risk Assessment
Reviewing Maintenance Procedures No Further Action Required
VIOLENT INCIDENTS: Should be completed by the manager if an act of violence has been reported
Name of Assailant:
Relationship to Council: (i.e. service user, pupil)
Circle one of the following that best describes the type of assault:
Attack by Animal Intimidating Behaviour Physical Injury Racial Sexual Threatening Behaviour Use of Weapon
Was incident reported to the police? Yes / No
If yes state which Police Station: and the Incident No:
Has support been given / offered to the employee following the incident? Yes / No
Was it necessary to use physical intervention? Yes / No
If yes state what technique was used:
Does the assailant have an individual risk assessment/care plan? Yes / No
If yes was the physical intervention technique used in accordance with it? Yes / No
Had all the employees who used restrictive physical intervention been trained? Yes / No
Revised: August 2012