3Was the injury (tick the one box that applies)
a major injury or condition? (see accompanying
an injury to an employee or self-employed person
which prevented them doing their normal work
for more than 3 days?
an injury to a member of the public which
meant they had to be taken from the scene
of the accident to a hospital for treatment?
4 Did the injured person (tick all the boxes that apply)
remain in hospital for more than 24 hours?
none of the above.
About the kind of accident
Please tick the one box that best describes what
happened, then go to Part G.
Contact with moving machinery or
material being machined
Hit by a moving, flying or falling object
Hit by a moving vehicle
Hit something fixed or stationary
Injured while handling, lifting or carrying
Slipped, tripped or fell on the same level
Fell from a height
How high was the fall?
Trapped by something collapsing
Drowned or asphyxiated
Exposed to, or in contact with, a harmful substance
Exposed to fire
Exposed to an explosion
Contact with electricity or an electrical discharge
Injured by an animal
Physically assaulted by a person
Another kind of accident (describe it in Part G)
Enter the number of the dangerous occurrence you are
reporting. (The numbers are given in the Regulations and in
the notes which accompany this form)
Describing what happened
Give as much detail as you can. For instance
• the name of any substance involved
• the name and type of any machine involved
•the events that led to the incident
•the part played by any people.
If it was a personal injury, give details of what the person was
doing. Describe any action that has since been taken to
prevent a similar incident. Use a separate piece of paper if you
Where to send the form
Incident Contact Centre, Caerphilly Business Centre,
Caerphilly Business Park, Caerphilly, CF83 3GG.
or email to email@example.com or fax to 0845 300 99 24
For official use
Client number Location number Event number
INV REP Y N