Part A
About you
1 What is your full name?
2 What is your job title?
3 What is your telephone number?
About your organisation
4 What is the name of your organisation?
5 What is its address and postcode?
6 What type of work does the organisation do?
Part B
About the incident
1 On what date did the incident happen?
2 At what time did the incident happen?
(Please use the 24-hour clock eg 0600)
3 Did the incident happen at the above address?
Ye s Go to question 4
No Where did the incident happen?
elsewhere in your organisation – give the
name, address and postcode
at someone else’s premises – give the
name, address and postcode
in a public place – give details of where it
If you do not know the postcode, what is
the name of the local authority?
4 In which department, or where on the premises,
did the incident happen?
Part C
About the injured person
If you are reporting a dangerous occurrence, go
to Part F. If more than one person was injured in the
same incident, please attach the details asked for in Part
C and Part D for each injured person.
1 What is their full name?
2 What is their home address and postcode?
3 What is their home phone number?
4How old are they?
5 Are they
6 What is their job title?
7Was the injured person (tick only one box)
one of your employees?
on a training scheme? Give details:
on work experience?
employed by someone else? Give details of the
self-employed and at work?
a member of the public?
Part D
About the injury
1What was the injury? (eg fracture, laceration)
2 What part of the body was injured?
Filling in this form
This form must be filled in by an employer or other responsible person.
Report of an injury or dangerous occurrence
F2508 (05.00)
Health and Safety at Work etc Act 1974
The Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995
Click here for report guidance
3Was the injury (tick the one box that applies)
a fatality?
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)
become unconscious?
need resuscitation?
remain in hospital for more than 24 hours?
none of the above.
Part E
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)
Part F
Dangerous occurrences
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)
Part G
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
need to.
Part H
Your signature
Where to send the form
Incident Contact Centre, Caerphilly Business Centre,
Caerphilly Business Park, Caerphilly, CF83 3GG.
or email to or fax to 0845 300 99 24
For official use
Client number Location number Event number
If returning by post/fax, please ensure this
form is signed, alternatively, if returning
by E-Mail, please type your name in the
signature box
Please continue on this page if necessary