B-SAFE Accident Report – Data Collection Form (Version 1.2)

1 BSAFE Accident Report Data Collection Form (Version )BSAFE MUST be used for reporting details of INJURIES that occur to our employees, visitors, pupils / children in our care, clientsor service users as a result of an Accident . IT IS NOT DESIGNED TO RECORD DETAILS OF OTHER SITUATIONS SUCH ASPHYSICAL RESTRAINTS UNLESS AN Accident INJURY OR NEAR MISS OCCURS AS A RESULT. IF RESTRAINTS NEEDTO BE RECORDED IT SHOULD BE DONE SO AT A LOCAL form is designed to assist users of BSAFE in collecting the necessary data required to submit Accident reports on the AccidentReporting module. Therefore, you do not have to use this form if you do not need to. You should enter a Report for any incidentwhich resulted in anything more than trivial first aid provision, or where the incident or near miss could have resulted in a seriousinjury. **If you have any queries about whether an incident should be reported contact CHSU on 01823 355089 **1.

2 ABOUT THE INCIDENTI ncident TypeAn injuryA minor injury Near missA case of diseaseA dangerous occurrence Date of incidentTimePlace of incidentElsewhere in your organisation At someone else s premises In a public place 2. DESCRIBING WHAT HAPPENED 3. WHAT HAPPENED Kind of incident (TICK ONE BOX)Animal or InsectrelatedExposedtoAsbestosHarassment RacialInjured whilsthandling, lifting orcarryingSlipped,tripped or fellon same levelViolence PhysicalAssault Deliberate Contact withelectricityExposedto FireHarassment SexualInjury not relatedto a specific eventSportViolence Restraint andControl IncidentContact with hotsurface or liquidExposed to, or contactwith, aharmful substanceHarassment OtherNone Near missStepping on /Strikingagainst a fixed or stationary objectViolence ThreateningIncidentContact with moving machinery ormaterials beingmachinedFall from bedHit by a moving vehicleOtherTrapped or crushed by somethingcollapsingViolence Verbal AssaultDrowned orasphyxiatedFallfromheightHit by a moving,flying or fallingobjectRepetitive StrainInjury (RSI)

3 Use of HandToolsWork relatednon-accidentalillnessExplosionFou ndon floorInjured whilstassisting clientRoad TrafficAccidentViolence PhysicalAssault Accidental 4. MAIN FACTOR INVOLVED IN THE incident ?Height of fall (if applicable)Name of alleged assailant (if applicable)Crime No. (if applicable)None - Near Miss Equipment/ Furniture - Office Hot Surface/ liquid Person - Other (Please statein description of incident ) Animal/ Insect - Dead Equipment/ Furniture - Other Ladder or scaffolding Person - Relative of Client/Service User/ Pupil Animal/ Insect - Live Explosion Machinery/ Equipment - Other Portable power or hand tools Any material, substanceor product beinghandled, used or stored Fire - Fire Fighting Machinery/ Equipment forlifting / conveying Process plant, pipe-work orbulk storage Building, engineeringstructure or excavation /underground working Floor, ground, stairs or anyworking surface Moveable container or packageof any kind Recurring injuryConstruction formwork,shuttering and falseworkGas, vapour, dust, fume oroxygen deficient atmosphere Pathogen or infected material Sport Electricity supply cable,wiring.

4 Apparatus orequipment Handling person Person - Client/ Service User/Pupil/ Member of the public Vehicle or associatedequipment / machinery Entertainment orsporting facilities orequipment Horseplay Person - Employee/ Colleague Violent incident iF YOU ARE RECORDING A DANGEROUS OCCURRENCE PLEASE CONTACT THE CORPORATE HEALTH & SAFETY UNIT on 01823 3550895. PEOPLE INVOLVED IN THE incident Consent given by the injured party to record personal information obtained? Name of injured party:_____ Date of Birth:_____Address: _____Job Title (if applicable): _____ Employee Contractor Public Client/service User Was the incident caused by an offending object or person? Yes/No Who or what was the offender? _____Nature of Injury including affected body part ( cut left leg, bruised right arm etc): _____Was the injured party: Participating in an activity Moving from A to B Passively involved in the situation Did the injured party go absent Yes/No?

5 First date of absence _____ Date returned to work _____6. WHAT HAPPENED IMMEDIATELY AFTER THE incident ?What date was the injured parties line manager made aware of the incident :Please tick all the boxes which describe the action taken following the incident First Aid GivenName of first aiderTaken HomeReturned to workTaken directly to hospital fromthe scene of the accidentAdmitted to HospitalNone of the aboveIf taken to hospital provide the following details if known Name of GP / Doctor that provided treatmentName and address of Hospital attended7. ADULT WITNESSES (This information should be collected for each witness) NameNumber of Witnesses (Max 5)012345 AddressConsent to record personal information obtained?Job Title (If appropriate)8. INVESTIGATIONS (By Manager) **THIS IS A MANDATORY FIELD**Each and every incident should be investigated. The investigation should be relevant to the type of incident that is being reported.

6 Where you are conducting a full investigation, further guidance is available using the Investigating Accidents document F18, available from the H&S Extranet. Some minor or trivial incidents may not require a full investigation. If this is the case, you should indicate why a full investigation has not been carried out. Sporting Injury No investigation reqd, or Known Behavioural issues No Investigation reqd, the time of the incident was the person authorised: To be where they were?To be doing what they were doing?When conducting a full investigation please note and comment on the following: Describe any remedical actions planned or implemented to help reduce the likelihood of this type of incident reoccurring? What lessons were learned from the incident ? Have you updated relevant documents policies, risk assessments etc and communicated these changes to people or teams you are responsible for? Do you require any further guidance or assistance from the Corporate Helath & Safety Unit in support of your investigations?

7 Have you uploaded any relevant documents photos, witness statements to B-SAFE that will support the investigation? Explain the outcome of any investigation or indicate why an investigation is not requiredYOU MAY SELECT 3 PEOPLE / MANAGERS TO BE AUTOMATICALLY ADVISED OF THIS Yes NoClose Report No Further Action once details have been entered onto the systemDATA CAPTURER .. DATE ..ENTERED ONTO BSAFE BY .. DATE ..YOU MUST ENSURE THAT THIS INFORMATION IS ENTERED ONTO BSAFE. A COPY OF THIS FORM DOES NOT NEED TO BE SENT TO CHSUFor queries or guidance contact the Corporate Health and Safety Unit on 01823 355089