TEMPLATE 3: INCIDENT/ACCIDENT REPORT FORM
ACCIDENT / INCIDENT REPORT FORM(This form is to be completed for all volunteers, service users and visitor accidents /incidents)Please fill in the churches accident form separately to this form and hand it into the office.All accidents/incidents to be reported. Wittiness statements to be taken/written where appropriate.Management is required to complete Section III, review the report for completeness and accuracy, sign and log thisreport in the accident/incident log book within 24 hours of the accident/incident. Note: the report (and pictures ifany) should then be filed together in a safe and secure location. Any copies of this report and any other relatedmaterials in conjunction with this report cannot be obtained without the authorization of management. Preserve evidence.Record all information as soon as possible.Use black pen.Keep writing clear and legible.Do not use jargon or abbreviate.Do not record your own opinion if you are filling the form in on behalf ofanother person.Use fact and the individuals own words, expressions, appearance, behaviourand views.SECTION I Do a body map where appropriate.Record what the circumstances in which the accident/incident cameabout.Note the setting and anyone else who was there at the time, andrecord this using their own words/phrases.Do not touch anything that may be evidence.If the incident was witnessed then the witness needs to do awitness statement and write down exactly what was seen.PLEASE PRINT OR TYPE ALL INFORMATIONName:TELEPHONE NUMBER:Address:Mobile phone number:Date of birth(why were you visiting?)Postcode:VolunteerService userTrusteeVisitorAge:
SECTION II ACCIDENT DATANATURE OFINCIDENT:Physical altercationAccident/InjuryDamage topropertyDATE of Accident/Incident:VerbalConfrontationOther: Please specifyTheft/BurglaryTime of Accident/Incident:ampmWhere did the Accident/IncidentOccurred? Address/location:Specific Location of Accident/IncidentExample: Bathroom, car park:Briefly explain what happened: Include mood of persons involeved and what was happening before the incident. If there was an injury,what happened to cause this injury or illness (3) what was the injury or illness (i.e., state the part of body affected and how it wasaffected) Use additional paper if needed.
What action was taken: Check all actions taken. If more than one, indicate which occurred 1st, 2nd, etc.First Aid – administered by:Medical help sought (What and where) :Sent HomeOther agencies informed:Continued Activity (no action taken)Social servicesPoliceRIDDOROther: Please specify:Other: please specify:Names and contact numbers of witnesses:Person Completing the Report:Signed:Print name:Date:Print name:Date:Reviewed by Risk Manager:Signed:Return form same day (or within 24 hours) of accidents/incident for employee, patron, or visitor to the Venues ManagementDepartment.
Accident/Incident Report FormSECTION IIIMANAGEMENT/SUPERVISOR REPORT ON THE ACCIDENT/INCIDENTWhat action has been taken to prevent such an accident/incident from recurring? Include specific details on how it wasmediated, how the incident can be avoided in the future. (take photos of environment following an incident):Management/Supervisor’s Account of Incident which supplements and/or clarifies information provided by injured party: (if aninjury, (1) explain activities occurring when injury or illness occurred and what tools, machinery, chemicals, were involved, (2) whathappened to cause this injury or illness (3) what was the injury or illness (i.e., state the part of body affected and how it wasaffected)Section III Completed by:Signature:Date:
SECTION IV-FOR INVESTIGATION/REVIEW ONLY - DO NOT WRITE BELOW THIS LINE:Investigation Comments: Photos are highly recommended immediately following an incident, if at all possible.Required Action:Section IV Completed by:SignatureDateDate sent to Board of trustees:
Management is required to complete Section III, review the report for completeness and accuracy, sign and log this report in the accident/incident log book within 24 hours of the accident/incident. Note: the report (and pictures if any) should then be filed together in a safe and secure location. Any copies of this report and any other related
accident reporting and investigation of each accident and incident (near-miss); and periodic review of the program to keep it up to date. The direct cause of an accident usually results from one or more previous unsafe actions or conditions. A good accident investigation program discovers the events leading up to an incident or accident.
cause analysis on a "near miss" or an accident can provide valuable information that could prevent a future accident. The state directs the use of three forms for reporting: o DA 2000, Employee Post Incident or Accident Analysis - - for employees. o DA 3000, Visitor /Client Post Incident or Accident Analysis - - for
RBC Insurance Accident Claim351.17 RBC Insurance Accident Claim188.37 Pilot Insurance Accident Claim259.95 State Farm Accident Claim182.16 State Farm Insurance Accident Claim178.70 Pafco Accident Claim115.46 Royal & Sunnaliance Accident Claim98.19
Incident Management Process Map 1. Incident Management Process Map 1. Incident Management Description and Goals 9. Incident Management Description and Goals 9. Description 9. Description 9. Goals 9. Goals 9. Incident Management RACI Information 10. Incident Management RACI Information 10. Incident Management Associated Artifacts Information 24
In GSM and GPS based accident detection system; GSM cellular technology is used to send the data in case of road accident. The location of the accident spot is identified by the GPS system. In VANET-based accident detection system, in case of an accident, information to the emergency department is sent using the VANET-an ad-hoc network
COMA (once per accident) Payable when an insured is in a coma lasting 30 days or more as the result of a covered accident. For the purposes of this benefit, Coma means a profound state of unconsciousness caused by a covered accident. 7,500 EMERGENCY DENTAL WORK (once per accident, within 6 months after the accident) Payable when an insured's natural teeth are
AND INVESTIGATION PLAN Accident/incident Reporting It is necessary to report every accident to your supervisor and the IGB Safety Coordinator in order to learn the cause and adopt proper methods to prevent any similar accident. The IGB . University Office of Risk Management: 217-333-3113. .
The Adventures of Tom Sawyer 4 of 353 She went to the open door and stood in it and looked out among the tomato vines and ‘jimpson’ weeds that constituted the garden. No Tom. So she lifted up her voice at an angle calculated for distance and shouted: ‘Y-o-u-u TOM!’ There was a slight noise behind her and she turned just
