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Edit Witness

Full Name *

Job Title

Address 1

Address 2

Address 3

Post/Zip Code

Tel

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What activities were being carried out at the time?

Were relevant safety precautions in place and operational?

What directly caused the injury or illness?

What were the environmental conditions at the time of the incident?

Injury Report

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Basic Information

I am reporting a work related:

Injury

Ill-Health

Near Miss

Incident Report Manager: *

Start Date:

Start Time:

Are you the person who had the accident?

Yes

Have the relevant line / area manager’s been directly notiﬁed?

Yes

Name of Manager / Supervisor?

Additional Details

What is your connection to the injured party?

Please specify

Does the person involved in the incident work in your organisation?

Why were they there?

Please specify

Please Enter Your Details Name: *

Email: *

Contact Number: *

Please provide details of the person who had the accident.

Full Name

Job Title

Address 1

Address 2

Address 3

Post/Zip Code

Tel

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Incident Details

Please specify location? *

Was the incident related to the work being done?

Yes

How was the incident related to work?

What happened? *

Was any equipment or substance involved?

Yes

Please specify if ‘yes’?

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Witnesses Information

Add Witness

Witness List

No witnesses added yet

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ABOUT THE INJURY OR NEAR-MISS

Complete this section to specify what the injury is & which part of the body are injured.

How serious is the injury? If it was a near-miss, how could somebody have been hurt?

Select injury type:

Amputation
Asphyxia (oxygen deprivation)
Back Pain
Bruising
Burns
Concussion
Crushing Injury
Dislocation
Electric Shock
Eye Injury / Loss of Sight
Fractures
Hand arm vibration syndrome (HAVS)
Hand or finger injury
Head or facial injury
Hearing loss or damage
Laceration / Cut
Poisoning
Sprain / Strain
Other

Which part(s) of the body is injured?

Ankle

Other body part

How serious was the injury?

Any further comments about the injury?

Specify other injury?

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First Aid & Follow-up Actions

Any First Aid given?

Yes

Who gave the first aid?

What was the next course of action for the person/s affected?

Select the applicable option

Back to Work To Doctor To Hospital Other

How much time was taken off work? (not including day of injury)

Select the applicable option

Less than 3 days More than 3 days More than 7 days

Please specify number of days

Select the applicable option

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ill Health

Complete this section to specify what the ill heath is.

You skip this section by clicking ‘Next’.

Select ill health type:

Allergic Reaction
Anxiety
Asbestosis
Asthma
Chest Pain
Dehydration
Fainting
Fatigue
Flu or fever
Headache or migraine
Heat exhaustion
Hypothermia
Nausea
Shock
Shortness of Breath
Sore Throat
Stress
Vomiting
Other

Any other comments about the ill-health?

Specify Other ill-Health?

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ABOUT THE INJURY OR NEAR-MISS

Complete this section to specify what the injury is & which part of the body are injured.

How serious is the injury? If it was a near-miss, how could somebody have been hurt?

Select potential injury type:

Amputation
Asphyxia (oxygen deprivation)
Back Pain
Bruising
Burns
Concussion
Crushing Injury
Dislocation
Electric Shock
Eye Injury / Loss of Sight
Fractures
Hand arm vibration syndrome (HAVS)
Hand or finger injury
Head or facial injury
Hearing loss or damage
Illness
Laceration / Cut
Poisoning
Sprain / Strain
Other

How serious was the injury?

Any further comments about the injury?

Specify other injury?

Back

Injury Report

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Add Witness

Were there any witnesses?

Yes

Full Name *

Job Title

Address 1

Address 2

Address 3

Post/Zip Code

Tel

Confirm Information Sharing

I consent to my personal information being shared.

We, Safety Apps Ltd, will store any incident reports that you submit on behalf of the relevant account holder. In relation to any personal data in an incident report, we act as a processor on behalf of the account holder; the account holder acts as controller. Using our software, the account holder may share that personal data with others. To find out more about how the account holder will handle personal data, you should read the privacy notice of the account holder.

What happened?

What activities were being carried out at the time?
Were relevant safety precautions in place and operational?
What directly caused the injury or illness?
What were the environmental conditions at the time of the incident?

Incident Report

Choose 'Overwrite' to update the existing report or 'Save as New' to create a separate one.

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Body Part(s)

Ankle
Back
Ear
Eye
Finger or Fingers
Foot
Hand
Head
Lower Limb
Neck
Other parts of Face
Toe
Trunk
Upper Limb
Wrist
Other

Job Title

Job Title:

Injured Body Part

Select Date

Choose a date

Injury Report

Basic Information

Additional Details

Please provide details of the person who had the accident.

Incident Details

Witnesses Information

About the Injury or Near-Miss

ABOUT THE INJURY OR NEAR-MISS

First Aid & Follow-up Actions

What was the next course of action for the person/s affected?

How much time was taken off work? (not including day of injury)

Please specify number of days

Ill Health Information

ill Health

Near Miss - Potential Injury Information

ABOUT THE INJURY OR NEAR-MISS

Injury Report

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