Document Sample
					                       HEALTH AND SAFETY INCIDENT REPORTING
                       Managers                              Employees/Non-employees

        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)
School Name:

Service Details: (i.e. Address of reporting establishment/team) (Please print in full)

Name of person completing form:

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
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)

Home address:

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

                                                                Verbal Abuse

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

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