SSCG ACCIDENT,INJURY,NEAR MISS REPORTING

SSCG ACCIDENT,INJURY,NEAR MISS REPORTING

1. Please complete all the boxes in this form
Person Reporting the incident *

First Name	*
Last Name	*
Job Title	*
Address Line 1	*
Address Line 2	*
Town	*
County	*
Post code	*
Mobile number	*
Email	*

2. Injured Persons Details *

First Name	*
Last Name	*
Place of Injury	*
Date of Injury	*
Address Line 1	*
Address Line 2	*
Town	*
County	*
Post Code	*
Gender	*
Age	*

3. Injured Persons Employment Status *

4. Summary of Event
i.e a brief description of the facts of what happened *

5. Is this a near Miss *

Yes
No
Don't know

6. is this a dangerous occurance *

Yes
No
Don't Know

7. Are you reporting an injured person *

Yes
No

8. is this an environmental event *

Yes
No

9. was the location SSCG Property *

Yes
No
Don't know

10. Type of injury(s) sustained *

11. Action Taken *

Self treated
treated by a registered first aider (please give name and contact details below)
Emergency services called
refusal of treatment

First Aider Details

12. What first aid was administered *

13. Did the person die as a result of the injury or injuries *

Yes
No

14. if No did the injuries prevent the individual from carryng out their routine work for more than 7 days *

Yes
No
Don't Know

15. was the individual taken to hospital *

Yes
No
No Sure

16. where was the incident reported to *

Company Office
Local Authorities
HSE