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Yes No  \nWhen did it happen/start?  \nDay:  \nDate:  \nTime:  \nWhere did it happen? (This should be as precise as possible. For example: Which building? Which room? Which area? Outdoors?–where exactly?)  \nIt happened in…  \nWhat happened? (Include what you were doing at the time and events that led up to it, including as much detail as you can. Try to describe it step-by-step. Include relevant details, such as light or weather conditions, if they may have affected what happened.)  \nSave time on HR admin. Try CharlieHR for free today    \nWas it related to the work being done or the place the work was being done?  \nYes No If Yes, then give details  \nWas any equipment or substance involved?  \nYes No If Yes, then give details  \nWas anything damaged?  \nYes No If Yes, then give details  \nDid you take any photos of the incident or injuries?  \nYes No  \nWere there any witnesses? (Complete details for each witness)  \n\n| Name | Job Title | Address |\n| --- | --- | --- |\n|  |  |  |\n|  |  |  |\n|  |  |  |\n\nSave time on HR admin. Try CharlieHR for free today    \nWhat do you think could have been done to prevent this incident? (If anything)  \nAbout an INJURY or NEAR MISS (What was the injury? Which parts of your body were injured? How serious was the injury? If it was a near-miss, how could you have been hurt?)  \n\n| Fracture (other than to fingers, thumbs and toes) |  |  |  |\n| --- | --- | --- | --- |\n| Amputation | |  |  |\n| An injury likely to lead to permanent loss of sight or reduction in sight |  | |  |\n| A crush injury to the head or torso causing damage to the brain or internal organs |  | |  |\n| Serious burns (including scalding) which cover more than 10% of the body or caused significant damage to the eyes, respiratory system or other vital organs |  |  | |\n| Scalping requiring hospital treatment | |  |  |\n| Loss of consciousness caused by head injury or asphyxia |  | |  |\n| An injury arising from working in an enclosed space (which led to hypothermia or heat-induced illness or required resuscitation or admittance to hospital for more than 24 hours). |  |  | |\n| Another injury? (What was the injury?) | |  |  |\n| Which part(s) of your body was/were injured? |  |  |  |\n| How serious was the injury? |  |  |  |\n| Any other comments about the injury? |  |  |  |\n\nSave time on HR admin. Try CharlieHR for free today    \nWas any first aid given?  \nYes No If Yes, then give details  \nWho gave the first aid?  \nWhat happened next?  \nBack to work Doctor Hospital Other  \nDetails about Hospital/Doctor/Other:  \nHow much time off was needed?  \n(Days) (not including the day of the injury)  \nAbout ILL-HEALTH  \n\n| Carpal tunnel syndrome |\n| --- |\n| Severe cramp of the hand or forearm |\n| Occupational dermatitis |\n| Hand-arm vibration syndrome |\n| Occupational asthma |\n| Tendonitis or tenosynovitis of the hand or forearm |\n| An occupational cancer |\n| A disease attributed to an occupational exposure to a biological agent |\n| Another form of ill-health? (What type of ill-health?) |\n| Any other comments about the ill-health? |\n\nSave time on HR admin. Try CharlieHR for free today    \nI consent to my personal information being shared:  \nYes No  \nSignature (if completed by hand):  \nDate form completed:  \nPerson completing this form (Only complete this if you are completing the form on behalf of someone else)  \n\n| Name: |\n| --- |\n| Job Title: |\n| Address: |\n| Connection with incident: |\n| Does the person involved in the incident work in your organisation?\u003Cbr>Yes No |\n| If not, in what capacity were they there? |\n| Signature (if completed by hand): |\n| Date form completed: |\n\nSave time on HR admin. Try CharlieHR for free today    \nEmployer Use ONLY  \n\n| Reported to RIDDOR? Yes No |\n| --- |\n| If YES, how was it reported? Telepho","cbCaiuJr5bYKZF2f","https://ap.wps.com/l/cbCaiuJr5bYKZF2f","pdf",148503,6,"English","# Workplace Accident Report\n## Employee details and incident description\n## Injury, ill-health, first aid and follow-up\n## Consent and signatures\n## Employer use only (RIDDOR reporting)","[{\"question\":\"What information does the employee report include?\",\"answer\":\"The form gathers employee details, whether they told their manager, the date/time, precise location, and a detailed step-by-step description of what happened. It also asks about work relation, equipment/substance involvement, damage, photos, witnesses, and prevention steps.\"},{\"question\":\"How does the form capture the injury or ill-health details?\",\"answer\":\"It requests the type of injury or near-miss harm, body parts affected, and severity, with fields for additional comments. It also includes a list of specific injury and ill-health categories and prompts for any other form of ill-health.\"},{\"question\":\"What does the employer section require?\",\"answer\":\"The employer section asks whether the incident was reported to RIDDOR, how it was reported (telephone or online), the date reported, actions taken, the date, and the name/signature if completed by hand.\"}]","Workplace Accident Report - Employee Injury Illness Near Miss Form | PDF"]