ACCIDENT, INCIDENT & NEAR MISS REPORT - eRiding

Part C – MAJOR INJURY Tick either box 01/ or 02 then one box 03 – 15Fatality 01 Major injury/condition 02Death of a person or persons 03 Any other injury requiring resusc’n 10Any fracture (other than fingers, thumbs, toes) 04 Admitted/remained in hospital (ovr 24hrs) 11Any amputation (traumatic or surgical) 05 Loss of consciousness from:Dislocated shoulder, hip knee or spine 06 Asphyxiation/harmful substance/biological agent. 12Loss of sight (temporary or permanent) 07 by: inhaled/ingested/absorbed through skin 13Eye injury (chemical or permanent) 08 Acute illness-bio.agent/toxin/infected material 14Electric shock/burn leading to unconsciousness 09Any other injury leading to hypothermia, heatorrequiring resusc’n or hospital (over 24 hrs) induced illness or unconsciousness 15If Box 1 or 2 is Ticked (as a result of work etc) Tel. HSE within 24 hrs + Form F2508 to HSE within 10 Days)Part D - MINOR INJURIES Tick one box 16 – 21a then one box 22 – 31aMore than 3 days incapacity to work 16 3 days absence 182 days & under absence 19 No absence 20 Near Miss Incident 21Taken to hospital for treatment :-(member of public, child, resident, etc) Not Employees 17 Not Known 21a(None Employees only)Fracture (fingers, thumbs, toes only) 22 Dislocation (other than shoulder, hip, knee or spine) 27Cuts / abrasions 23 Foreign body in eye (grit etc) 28Bruising 24 Minor electric shock/burn 30Strains / sprains 25 Other (describe in details of accident box) 31Minor burns / scalds 26 No other Injury (describe in details of accident box 31aIf Box 01, 02, 16 or 21 is Ticked (as a result of work etc – Contact SSU ASAPIf Dangerous Occurrence: tick one of the above codes between 03 – 15 or 22 to 31a and 999 belowDangerous Occurrence (999) Reference Number TypePart E – AGENT OF INJURY (Please tick One Box 32 – 41a)Machinery 32 Hand Tool 33 Vehicle 34Ground or surface 35 Building 36 Physical Object 37Other 40 None 41a