3Was the injury (tick the one box that applies)
a fatality?
a major injury or condition? (see accompanying
notes)
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
Signature
Date
Where to send the form
Incident Contact Centre, Caerphilly Business Centre,
Caerphilly Business Park, Caerphilly, CF83 3GG.
or email to riddor@natbrit.com or fax to 0845 300 99 24
metres
For official use
Client number Location number Event number
INV REP Y N
