Primary If employee: Secondary Line manager’s Type of school: name and contact details: Puncture wound / Affected vision Crush Infection sharps / needle stick injury Bite or animal) Death Inappropriate touching Skin irritation How was the person Bump / bruise(s) Emotional shock Loss of limb or digit Strain / sprain affected? Stress arising from Burn / scald Fracture / dislocation Not applicable (no injury) (Please mark work practices all that apply): Chipped / broken Graze / cut / scratch Pain only Unconsciousness tooth/teeth Illness (including Other (please state): Poison by consumption / Concussion seizure / stroke / ingestion cardiac arrest.) Abdomen Emotional harm Jaw Thigh Which part(s) of the body Ankle Eye Knee were injured? Other (e.g. internal Arm Face Mouth (mark all that organ) please state: – apply): Back Finger / Thumb / Toe Neck If relevant, Nose Buttocks Foot please Chest Hand Pelvis / Hip indicate: Not applicable (i.e. no Ear Head / Scalp Shin / Calf L = Left, bodily harm) R = Right or Elbow Collarbone Genitalia Shoulder / B = Both Section 4: After the incident What happended to the Went to hospital from the scene of Remained at school Sent home the incident injured person after the incident: Other (please state): Y / N Was first aid administered? First aider’s name / contact: If please detail: ‘yes’ Y / N / Not known If the injured party went to hospital did they receive Relevant details: treatment? If employee - are they absent from work as a Y / N result? If please note first date Date absent from: Date returned to work: ‘yes’ – absent and notify your H&S Advisor of their return. If over seven days please inform immdiately. Was a GP / hospital fit note Y/ N If please send fit note with this form ‘yes’, submitted? Section 5: Further information Y / N Were any What has been done witnesses to to prevent further If yes, who? Contact details and the incident? incidents of this attach brief statement if given: nature? If please ‘yes’ give details: (Continue on separate sheet if needed).
If employee: Line manager’s name and contact details: Type of school: Primary Secondary How was the person affected? (Please mark all that apply): Affected vision Crush Infection Puncture wound / sharps / needle stick injury Bite or animal) Death Inappropriate touching Skin irritation Bump / bruise(s) Emotional shock Loss of limb or digit Strain / sprain Burn / scald Fracture / dislocation Not applicable (no injury) Stress arising from work practices Chipped / broken tooth/teeth Graze / cut / scratch Pain only Unconsciousness Concussion Illness (including seizure / stroke / cardiac arrest.) Poison by consumption / ingestion Other (please state): Which part(s) of the body were injured? (mark all that apply): If relevant, please indicate: L = Left, R = Right or B = Both Abdomen Emotional harm Jaw Thigh Ankle Eye Knee Arm Face Mouth Other (e.g. internal organ) – please state: Back Finger / Thumb / Toe Neck Buttocks Foot Nose Chest Hand Pelvis / Hip Ear Head / Scalp Shin / Calf Not applicable (i.e. no bodily harm) Elbow Genitalia Shoulder / Collarbone Section 4: After the incident What happended to the injured person after the incident: Remained at school Went to hospital from the scene of the incident Sent home Other (please state): Was first aid administered? If ‘yes’ please detail: Y / N First aider’s name / contact: If the injured party went to hospital did they receive treatment? Y / N / Not known Relevant details: If employee - are they absent from work as a result? Y / N If ‘yes’ – please note first date absent and notify your H&S Advisor of their return. Date absent from: Date returned to work: If over seven days please inform immdiately. Was a GP / hospital fit note submitted? Y/ N If ‘yes’, please send fit note with this form Section 5: Further information Were any witnesses to the incident? If ‘yes’ please give details: Y / N If yes, who? Contact details and attach brief statement if given: What has been done to prevent further incidents of this nature? (Continue on separate sheet if needed).
Incident_report_form_FEB_18_UPDATE.docx