Accident or Dangerous Incident Report Form
The Trust is committed to visitor safety at all its sites. Finding out about accidents or
incidents, and learning from them will help the Trust to manage visitor safety effectively.
To report an accident or dangerous incident which has occurred on a Trust site or was
connected to Trust activities, please complete this form and return to
carolinedavison@norfarchtrust.org.uk
1 About you
Name:
Telephone number:
Email address:
(please check your email is correct as we will send an acknowledgement of receipt via this
address)
Status:
(e.g. Employee/Member of the Public/Volunteer)
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About the incident
On what date did the incident happen?
At what time did the incident happen?
(Please use 24 hour clock)
Where did the incident happen?
(Please tell us the site address, and also exactly where on the site the incident took place.
Please provide a photo or sketch plan where possible)
Please describe the incident:
(Please include as much details as possible for example, the weather, equipment being
used, other people involved)
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3
About the injured person


If no-one was injured please insert ‘not applicable’ and go to Section 5
If more than one person was injured please provide the information requested for
each person
What is their full name?
What is their home address and postcode?
How old are they?
Are they male or female?
Was the injured person (please tick):
 A member of the public
 A volunteer at the site
 Self-employed and at work
 An employee working on the site
 Other (please state)
Continue on next page…….
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4
About the injury
a) Did the injury result in a death? Yes
No
b) If No, was the injury to a worker/volunteer?
Yes
No
(if ‘No’ please go to part (e) of this question)
c) If the injury was to a worker/volunteer, was the injury one of these in the list
below? (please tick):












fractures, other than to fingers, thumbs and toes
amputations
any injury likely to lead to permanent loss of sight or reduction in sight
any crush injury to the head or torso causing damage to the brain or internal
organs
serious burns (including scalding) which:
covers more than 10% of the body
causes significant damage to the eyes, respiratory system or other vital organs
any scalping requiring hospital treatment
any loss of consciousness caused by head injury or asphyxia
any other injury arising from working in an enclosed space which:
lead to hypothermia or heat-induced illness
required resuscitation or admittance to hospital for more than 24 hours
d) Did the injury prevent a worker/volunteer from carrying out their routine work
for more than 7 days?
Yes
No
OR
e) Was the injury to a member of the public who was taken directly to hospital?
Yes
No
Please describe the injury:
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5
Witnesses
(Please complete this info if you have the contact details of other witnesses to the incident
– if there were more than two witnesses please add information as appropriate)
Witness 1
Name:
Witness 2
Name
Address/Phone no:
Address/Phone no:
Status:
(e.g. Employer/Passer-by/Family member)
Status:
Thank you for completing this form.
Please send it to carolinedavison@norfarchtrust.org.uk
Office use only
Witness 1:
Written statement: Y/N
Electronic file reference:
Severity:
Witness 2:
Y/N
Near-miss / Minor / Significant / Serious
Action taken to prevent recurrence:
Health and safety report
Action:
Accident report received..........................................
Recorded (on computer)..........................................
Investigated (date/by)...............................................
RIDDOR reported (date)...........................................
RIDDOR reported (method)......................................
Signature:
Date:
Date:
Last update 22.05.15CD
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