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*
Date*

DayMonthYear
Date
OFFICE USE ONLY
In an emergency or serious injury inform Headteacher immediately
- 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
- Date
  
  DayMonthYear
  Date
- RIDDOR CLASSIFICATION:
  
  These classify/confirms if the injury is subject to RIDDOR legislation and such will need to be reported to the Health & Safety Executive. There is no requirement to check that the hospital actually gave the treatment. The requirement to report is based on the pupil/person taken to the hospital for treatment of an injury. if an injury identified at the scene is requiring hospital treatment, this should be reported. If no injury is evident and the school receives no information that any injury has been treated, no report is required.
  
  See RIDDOR guidance HERE:
  
  - RIDDOR - Dangerous Occurrence
  
  - RIDDOR - Fatality
  
  - RIDDOR - Major injury or condition
  
  - RIDDOR - Member of the public taken to hospital
  
  - RIDDOR - Staff absence over 7 days
  
  - RIDDOR - Pupil taken straight to hospital received treatment
  
  - RIDDOR - Reportable occupational disease or condition of staff
  
  - Not RIDDOR - Examination shows no injury
- Any injury at the scene that requires treatment is a reportable RIDDOR, is this accident/incident is a RIDDOR
  
  YesNo
- Please select the appropriate if this incident is RIDDOR?
  
  RIDDOR - Dangerous OccurrenceRIDDOR - FatalityRIDDOR - Major injury or conditionRIDDOR - Member of the public taken to hospitalRIDDOR - Staff absence over 7 daysRIDDOR - Pupil taken straight to hospital received treatmentRIDDOR - Reportable occupational disease or condition of staffRIDDOR - Flammable gas incidentRIDDOR - Dangerous gas fitting
- Click here to report the RIDDOR.
- Have you reported this incident to the HSE?
  
  YesN/A
- If yes, please attach HSE confirmation email/doc*
  
  Cancelof
- HSE RIDDOR Reference Number*
- Date of Submission*
  
  DayMonthYear
  Date
- Name of the person reported to the HSE?*
- Signature (person who reported to the HSE)*
- Date*
  
  DayMonthYear
  Date
- Was time lost due to staff absence?
  
  YesNo time lost
- Staff first day absence*
  
  DayMonthYear
  Date
- Staff last day absence*
  
  DayMonthYear
  Date
- 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*
- Date*
  
  DayMonthYear
  Date
- Should be Empty:

Accident & Reporting Form (CS2)

OFFICE USE ONLY