INCIDENT DATE by pptfiles

VIEWS: 60 PAGES: 4

									                            BBC ACCIDENT/INCIDENT NOTIFICATION FORM (accessible version)

 BBC Health and Safety arrangements require all accidents and incidents to be reported by the Injured Person or by the person
 in charge of the activity, as soon after the incident as possible and it must be a true and accurate statement of what
 happened. This form can be used to make a temporary record the details of the accident/incident until you can
 record it on myRisks Tools. Please complete all sections. For guidance see: BBC Accident Reporting Procedures. This record
 of an accident or injury is used in place of the Form BI 510 Accident Book under the Social Security (Claims and Payments)
 Regulations 1979.

 Personal information collected during incident reporting and investigation will be used to fulfil the BBC's obligations under Health
 and Safety policy and legislation. It will be retained for up to 6 years after the incident. It may be shared with other
 organisations, including our agents and contractors, with whom the risk or the control of risk is shared. You have the right to
 confirm that any information held about you is correct.

 Safety Representatives undertaking their statutory functions may carry out an inspection of the area concerned and speak to staff
 in order to determine the cause of the accident and may request information on this form. Personal details can only be provided
 with the consent of the person to whom they relate. This form can be read by screen readers such as JAWS.
INCIDENT DATE                       INCIDENT TIME                       REPORT DATE                          REPORT TIME


INCIDENT OWNERSHIP [Which department does the injured person (IP) work for OR which department was in charge of the activity?]
Division                            Department                          Business unit                      Programme/Event              (if applicable)




INCIDENT DESCRIPTION
Give as much detail as you can, e.g. name any substance or equipment involved, events leading up to the accident or incident
including what was happening at the time, the part played by any people, what the injured person (if applicable) was doing at the
time of the Incident and if the injured person has been off work as a result of the incident. Please include any external
organisations already contacted (for example, Police, Fire, Ambulance, HSE, Environment Agency)

Note: For the purposes of data protection, names of individuals should not be used in this section - please use IP for
injured person, or the terms 1st / 2nd on scene etc and witness, as appropriate.



Did it occur on a BBC Site          Region                              Location                             Area

    YES            NO

INCIDENT LOCATION [Please give exact details of the location at which the incident took place, including details of site
management/ownership/contact details if not BBC premises: ]




HOW MANY PEOPLE WERE INVOLVED? Add details for 2 nd / 3rd person at end of form                              0

PERSON INVOLVED: [IF MORE THAN ONE PERSON INVOLVED ADD DETAILS IN SECTIONS AT END OF FORM]
Serious accidents and incidents, which include those resulting in broken bones, days away from work, any hospital treatment or
involving the emergency services, must be reported to BBC Safety by phone or email as soon as possible. They will also be able to
help you decide what to do next.
Is consent given for details of their involvement in this incident being passed to                                YES               NO
their union representative?

Category of person:               Employee         Contractor        Freelance        Artist/Contributor         Member of Public               Other

Nature of                         Injured Person/victim           Other involvement          Witness        First on scene
involvement:
Title:                              First Name:                                   Last Name:                 Staff No:



Contact Tel No:                                                                   Email address:

Contact address (if non-BBC staff):                                               Home address: (of injured person)



OTHER WORK DETAILS
Occupation                          Team Leader or Supervisor                     Department Head



   If you need help completing this form, please contact: Safety Advice Line (0370 411) 0464
   1b3885f0-7552-44a8-b615-c5082a64e208.doc              1 of 4                                                            02/02/2011
                           BBC ACCIDENT/INCIDENT NOTIFICATION FORM (accessible version)
DETAILS OF INJURY AND RESULTING ABSENCE FROM WORK:

                                        Body Location: [arm, leg        Body Sub Category: [toe,        Body Side [left, right, both]
Nature of Injury:                                                       finger etc]
                                        etc]



Was treatment given, if              No treatment given            Treatment offered but refused          at scene
yes where was it given?              at local first aid point       at Occupational Health     at local GP surgery             at hospital
Date of treatment:                                                    Time of treatment:
Nature of treatment ,
Provided by:
Became unconscious?                   YES           NO                  Required resuscitation?            YES            NO
In hospital >24hrs?                  YES
                                  ;Yes              NO
                                      Returned to Work             Referred to hospital       Sent or taken to hospital
After treatment:
                                      Referred to dentist            Referred to own GP            Sent or taken home
                                      By organisation vehicle           By hospital vehicle        By private vehicle          by taxi
Mode of transport (if                 by ambulance              by air ambulance       By other means          unknown
applicable):
                                      Not applicable

Next of-kin notified?                 YES           NO
HOURS OF WORK ON THE DAY OF THE INCIDENT

Start Time:                                                            End Time
Other relevant information
[Please record further details
as appropriate about this
person]

DAMAGE DETAILS

Item Damaged:


Details:



OTHER INFORMATION AND CORRECTIVE ACTION [What immediate action has been taken to prevent a recurrence and by whom?]




Has the injured person been referred to BBC Occupational Health for a return to work fitness                            YES              NO
assessment?

INCIDENT REPORTED BY

NAME
DATE
Please save this form and email it to your line manager, having completed
details about 2 nd / 3rd persons involved below, if appropriate.




  If you need help completing this form, please contact: Safety Advice Line (0370 411) 0464
  1b3885f0-7552-44a8-b615-c5082a64e208.doc             2 of 4                                                     02/02/2011
                            BBC ACCIDENT/INCIDENT NOTIFICATION FORM (accessible version)

Details of other persons involved.
2nd PERSON INVOLVED: [ADD DETAILS HERE]
Is consent given for details of their involvement in this incident being passed                           YES              NO
to their union representative?

Category of person:               Employee         Contractor        Freelance       Artist/Contributor         Member of Public          Other

Nature of involvement:            Injured Person/victim           Other involvement         Witness        First on scene
Title:                             First Name:                                   Last Name:                 Staff No:



Contact Tel No:                                                                  Email address:

Contact address (if non-BBC staff):                                              Home address: (of injured person)




OTHER WORK DETAILS
Occupation                         Team Leader or Supervisor                     Department Head


DETAILS OF INJURY AND RESULTING ABSENCE FROM WORK:

                                         Body Location: [arm, leg         Body Sub Category: [toe,         Body Side [left, right, both]
Nature of Injury:                                                         finger etc]
                                         etc]



Was treatment given, if                No treatment given            Treatment offered but refused              at scene
yes where was it given?                at local first aid point       at Occupational Health          at local GP surgery          at hospital
Date of treatment:                                                      Time of treatment:
Nature of treatment ,
Provided by:
Became unconscious?                    YES            NO                  Required resuscitation?               YES             NO
In hospital >24hrs?                   YES
                                   ;Yes               NO
                                       Returned to Work              Referred to hospital         Sent or taken to hospital
After treatment:
                                       Referred to dentist             Referred to own GP              Sent or taken home
                                       By organisation vehicle            By hospital vehicle         By private vehicle           by taxi
Mode of transport (if                  by ambulance               by air ambulance        By other means            unknown
applicable):
                                       Not applicable

Next of-kin notified?                  YES            NO
HOURS OF WORK ON THE DAY OF THE INCIDENT
Start Time:                                                             End Time
Other relevant information
[Please record further details
as appropriate about this
person]




   If you need help completing this form, please contact: Safety Advice Line (0370 411) 0464
   1b3885f0-7552-44a8-b615-c5082a64e208.doc             3 of 4                                                        02/02/2011
                            BBC ACCIDENT/INCIDENT NOTIFICATION FORM (accessible version)


3rd PERSON INVOLVED: [ADD DETAILS HERE]
Is consent given for details of their involvement in this incident being passed                           YES              NO
to their union representative?

Category of person:               Employee         Contractor        Freelance       Artist/Contributor         Member of Public          Other

Nature of involvement:            Injured Person/victim           Other involvement         Witness        First on scene
Title:                             First Name:                                   Last Name:                 Staff No:



Contact Tel No:                                                                  Email address:

Contact address (if non-BBC staff):                                              Home address: (of injured person)




OTHER WORK DETAILS
Occupation                         Team Leader or Supervisor                     Department Head


DETAILS OF INJURY AND RESULTING ABSENCE FROM WORK:

                                         Body Location: [arm, leg         Body Sub Category: [toe,         Body Side [left, right, both]
Nature of Injury:                                                         finger etc]
                                         etc]



Was treatment given, if                No treatment given            Treatment offered but refused              at scene
yes where was it given?                at local first aid point       at Occupational Health          at local GP surgery          at hospital
Date of treatment:                                                      Time of treatment:
Nature of treatment ,
Provided by:
Became unconscious?                    YES            NO                  Required resuscitation?               YES             NO
In hospital >24hrs?                   YES
                                   ;Yes               NO
                                       Returned to Work              Referred to hospital         Sent or taken to hospital
After treatment:
                                       Referred to dentist             Referred to own GP              Sent or taken home
                                       By organisation vehicle            By hospital vehicle         By private vehicle           by taxi
Mode of transport (if                  by ambulance               by air ambulance        By other means            unknown
applicable):
                                       Not applicable

Next of-kin notified?                  YES            NO
HOURS OF WORK ON THE DAY OF THE INCIDENT
Start Time:                                                             End Time
Other relevant information
[Please record further details
as appropriate about this
person]
Completed
If more than three persons are involved please use a second form to record the information about the additional persons and submit
this too. When the information is entered into the electronic Incident report on myRisks there are tabs to enter records about
everyone involved.




   If you need help completing this form, please contact: Safety Advice Line (0370 411) 0464
   1b3885f0-7552-44a8-b615-c5082a64e208.doc             4 of 4                                                        02/02/2011
 form, please contact: Safety Advice Line (0370 411) 0464
   1b3885f0-7552-44a8-b615-c5082a64e208.doc              4 of 4                                                          30/11/2010

								
To top