Accident & Reporting Form (CS2)

Accident & Reporting Form (CS2)

CORPORATE HEALTH AND SAFETY TEAM
Full Name of the person affected*
Gender*

MaleFemale
Date of Birth*

DayMonthYear
Date
Incident Date*

DayMonthYear
Date
Time of Incident*

Hour Minutes
Are you*

Employee of Adamsrill Primary SchoolAgency StaffContractorPupil of the schoolClientMember of Public
If you are a contractor, please state the name of your line manager?*
Pupil's Date of Birth*

DayMonthYear
Date
If you are a member of public, please state the reason for being on site?*
Area of accident*

On-SiteOff-Site
Please state area/place/location of the accident?*
e.g. Y5 classroom, sports hall, outside the main gate
Full Name and Job Title of the person reporting the incident*
Description of Incident /Accident (describe what happened*
Nature of Injury (Please select most appropriate)*

AbrasionAmputationAsphyxiationBiteBruiseBumpBumped head, no visible injuryCrushingCut and bruisedCut lacerationDeafnessDislocationElectric shock/burnEpilepsyAsthma AttackFaintingFatalityForeign bodySubstance in the eyeFractureHeart AttackNone visibleNose bleedOvercome by fumes/vapourPoisoned by inhaled /swallowed substancePsychologicalScaldShock (not electric)Skin irritationSprain or strainSuspected fracture (awaiting confirmation)Teeth damageThroat/lung irritationOther type of injuryNo injuryNot known
Part of the Body (if no injury state N/A)*
Primary cause of Incident/Accident (Please select most appropriate)*

Abuse verbal threatening behaviourAssault by pupil/client on an employeeAssault by a pupil/client on pupil clientAssault by a member of the public on an employeeAssault by pupil/client on pupil/clientContact with electricity/dischargeContact with machinery/machined materialContact with moving/flying/falling object/personContact with something fixed or stationeryContact with sharp educe inc needlesDangerous occurrenceDrowned or asphyxiatedExposure to an explosionExposure to fire/heatExposure/contact to a harmful susbtanceExposure/contact with hot material/substanceFall from heightHuman biteIllnessIncident/accident involving vehicleInjured by an animal/insectInjured whilst manually handling lifting/carryingKnown medical conditionNear missProperty/equipment damage onlySlip/trip/fall on same levelSwallowed inhaled substanceSwimming diving related activityTrapped by something collapsing/overturningAnother kind of accidentNot known
Secondary cause of incident/accident - What contributed to the accident/incident*

Environmental - condition of premises weatherMaterial & equipment how they are designed and usedpersonal factors - competence, health and fitness, fatigue, language, communicationWork organization - task, procedures, management, supervision and training
First Aid administered to Adult?*

YesNo
If yes, name of first aider?*
Did affected person attended the Hospital or got treatment from paramedics?*

YesNo
Signature*

Clear
Date*

DayMonthYear
Date
OFFICE USE ONLY
In an emergency or serious injury inform Headteacher immediately

Premises Manager Section
Was Premises Manager notified?

YesN/A
Risk Assessment completed by Premises Manager?

YesN/A
Action taken to prevent further risk: please complete below
Premises Manager Signature

Clear
Date

DayMonthYear
Date

Investigator Section
Was it investigated?

YesNo
Who investigated it?*

HeadteacherSBMOther SLT MemberPremises Manager
Name of the person who investigated it?*
Action to prevent reoccurrence. Please complete below. *
Investigator Signature*

Clear
Date*

DayMonthYear
Date

Should be Empty:

Accident & Reporting Form (CS2)

OFFICE USE ONLY