Determination Meets standards no further action – Meets standards with minor changes Meets standards with major changes Fails to meet Recommendations / Actions Deadline for action Name of Assessor Role Date Appendix 3 Example of South Ayrshire Council Internal Incident Report Form SOUTH AYRSHIRE COUNCIL OFFICE USE ONLY INTERNAL INCIDENT REPORT FORM Code: To be completed in accordance with SAC Incident Reporting & Investigation Standard for all work-related incidents occurring Investigation within Council controlled property, involving Council employees, persons the supervision of the Council, contractors or Date: other members of the public. Complete all sections in CAPITALS and in black ink. Send the completed original AR1 Form to Corporate Safety Team and retain a copy for your own records. DIRECTORATE: SERVICE: REF: A - INJURED PERSON’S DETAILS (if relevant) Full Name: Work Base: Home Address: Address: Postcode: Tel: Occupation: SEX: Council Employee Member Employee under18 Client/Pupil Status: Date of Age: M F of Public Contractor Other
Determination Meets standards – no further action Meets standards with minor changes Meets standards with major changes Fails to meet Recommendations / Actions Deadline for action Name of Assessor Role Date Appendix 3 Example of South Ayrshire Council Internal Incident Report Form SOUTH AYRSHIRE COUNCIL INTERNAL INCIDENT REPORT FORM OFFICE USE ONLY Code: Investigation Date: To be completed in accordance with SAC Incident Reporting & Investigation Standard for all work-related incidents occurring within Council controlled property, involving Council employees, persons the supervision of the Council, contractors or other members of the public. Complete all sections in CAPITALS and in black ink. Send the completed original AR1 Form to Corporate Safety Team and retain a copy for your own records. DIRECTORATE: SERVICE: REF: A - INJURED PERSON’S DETAILS (if relevant) Full Name: Work Base: Home Address: Address: Postcode: Tel: Occupation: Date of Age: SEX: M F Status: Council Employee Member of Public Employee under18 Contractor Client/Pupil Other