Injury sustained? Yes No Nature of Injury Part of Body Method of injury Abrasion Abdomen Asphyxiation Absorption Ankle Assault - physical Bitten Arm Assault – verbal Bruise Back Bite/sting Burn Chest Burn Choke Elbow Contact moving machine Crush Eye Contact sharp object Cut Finger Contact stationary object Dislocation Foot Electric shock Electric shock Forehead Explosion Fracture Hand Exposure to substance Hearing damage Head Fall less than 2m high Illness/medical Hip Fall more than 2m high Infection Internal Fire Inhalation Knee Flooding Irritation Leg Manual handling Multiple injuries Mouth Road traffic Poison Multiple areas Self-harm Puncture Neck Slip and trip (wet/slippery) Rash Nose Slip and trip (uneven) Scald Shin Sports injury Seizure Shoulder Struck by falling object Sprain Thigh Struck by moving machine Strain Thumb Other Not Known Toe Potential Injury Wrist Not Known/Other This form must be completed and sent to the Health & Safety Office within 24hrs Signature of person reporting: Date: Signature of injured person: Date: Signatures confirm that the information given accurately records the event. Email to Telephone enquiries 07894 622 115
Injury sustained? Yes No Nature of Injury Abrasion Absorption Bitten Bruise Burn Choke Crush Cut Dislocation Electric shock Fracture Hearing damage Illness/medical Infection Inhalation Irritation Multiple injuries Poison Puncture Rash Scald Seizure Sprain Strain Not Known Potential Injury Part of Body Abdomen Ankle Arm Back Chest Elbow Eye Finger Foot Forehead Hand Head Hip Internal Knee Leg Mouth Multiple areas Neck Nose Shin Shoulder Thigh Thumb Toe Wrist Not Known/Other Method of injury Asphyxiation Assault - physical Assault – verbal Bite/sting Burn Contact moving machine Contact sharp object Contact stationary object Electric shock Explosion Exposure to substance Fall less than 2m high Fall more than 2m high Fire Flooding Manual handling Road traffic Self-harm Slip and trip (wet/slippery) Slip and trip (uneven) Sports injury Struck by falling object Struck by moving machine Other This form must be completed and sent to the Health & Safety Office within 24hrs Signature of person reporting: Date: Signature of injured person: Date: Signatures confirm that the information given accurately records the event. Email to Telephone enquiries 07894 622 115
Goldsmiths-Accident-Form.docx