Name *

Person Completing the Form

First Name

Last Name

Date *

MM

DD

YYYY

Name *

Injured Person

First Name

Last Name

People Involved *

Young Person

Staff

Volunteer

Member of Public

Contractor

Other

First Aid Administered *

Yes

No

Were The Emergency Services Called? *

Ambulance

Fire Brigade

Police

No

Has the injured party had time off from work as a result of this incident? *

Yes

No

Date

MM

DD

YYYY

If required, has Facilities Dept been notified for insurance purposes? *

Yes

No

Date

MM

DD

YYYY

If required, has Crisis Management – Managing Communications Policy been actioned? *

Yes

No

Date

MM

DD

YYYY

Was a risk assessment carried out for the person/activity/workspace? *

Yes

No

Are there systems/policies (local or corporate) in place designed to prevent incidents of this nature? *

Yes

No

Do these systems/policies require review in the light of this incident? *

Yes

No

Were the relevant parties aware of any relevant policies/systems? *

Yes

No

Has this incident highlighted a need for any further systems or policy development and/or training and/or communication? *

Yes

No

Would any changes to the environment or work processes prevent or limit the impact of a reoccurrence of this incident? (e.g personal alarms) *

Yes

No

Are there any aspects of this incident that in your view expose Look Inside to any reputational or other risks? *

Yes

No

Reviewed By *

First Name

Last Name

Date *

MM

DD

YYYY

Nature of Incident *

1. Manual Handling/ Lifting

2. Security

3. Physical Assault

4. Contact with Hot/Cold Surface

5. Food Hygiene

6. Slip/Trip/Fall

7. Fire/ Explosion

8. Personal Accident

9. Exposure to Harmful Substance

10. Environmental

11. Electricity

12. Ill Health

13. Sports injury

14. Equipment/ Machinery Failure

15. Outdoor Activity

16. Struck against object

17. Struck by moving object

18.Motor Vehicle

19. Near Miss

20. Verbal Abuse

21. Written Abuse

22. Threats

23. Violent/Aggressive Behaviour

24. Other