Is this a recurring injury / health problem: CONTACTS Please provide full details, including name, address and contact number of anyone involved in the incident including witnesses or any treatment providers: POLICE INVOLVEMENT Were the police involved: If so, please provide full contact details of the police officer: Time and Date police were called: Incident number: Crime number: Actions taken by police: FURTHER DETAILS Does this need to be reported externally: RIDDOR reportable: Potential for Complaint: Potential for Claim: Please type YES into the greyed box which states the score that is most appropriate to this incident. Signature of reporter: Date: Name of designated manager: Job Contact details:
Is this a recurring injury / health problem: CONTACTS Please provide full details, including name, address and contact number of anyone involved in the incident including witnesses or any treatment providers: POLICE INVOLVEMENT Were the police involved: If so, please provide full contact details of the police officer: Time and Date police were called: Incident number: Crime number: Actions taken by police: FURTHER DETAILS Does this need to be reported externally: RIDDOR reportable: Potential for Complaint: Potential for Claim: Please type YES into the greyed box which states the score that is most appropriate to this incident. Signature of reporter: Date: Name of designated manager: Job Contact details:
Incident-reporting-form-IR1-template-West-Lancs.docx