REPORT OF AN INJURY

This is a template of HSE on line report form. Use it to gather the information that you will be
required to input when using the HSE’s on-line reporting system.

Notification Number Automatically generated by the on-line reporting system

About you and your organisation.
   
Your name: Title Forename       Family name      
  

Job Title:       Your Phone No      

Organisation Name      

Address 1      
Address 2      
Address 3      
Town      
County      
Post Code       Fax Number      
E-Mail      
Did the incident happen at the above address? Yes No
Which authority is responsible for monitoring and inspecting health HSE Local Authority
and safety where the incident happened?

About where the incident happened.

(only required when the accident did not occur at the address given above)

Where did the incident happen?

Elsewhere in your organisation At someone else’s premises In a public place
Address 1      
Address 2      
Address 3      
Town      
County      
Post Code      

Details of where accident happened (if the address is unknown)

     

About the incident.

Incident date Incident time
            (24 hour clock)

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In which local authority did the incident occur?
Country Geographical Area Local Authority
Select from drop down list Select from drop down list Select from drop down list

In which department or where on the premises/site, did the incident happen?

     
What type of work was being carried out (generally the main business activity of the site)?
Main industry (select one industry from drop down list)

̵ Agriculture, Forestry, Fishing, Veterinary

̵ Mining, Quarrying
̵ Manufacture Food, Drink, Tobacco
̵ Manufacture Textiles, Leather
̵ Manufacture Coke, Petroleum, Chemicals, Pharmaceuticals
̵ Manufacture Computer, Electronic, Light Electrical
̵ Manufacture Machinery, Vehicle, Transport
̵ Machinery Repair excluding Motor Vehicles
̵ All Other Manufacturing
̵ Utilities, Sewerage, Waste and Recycling
̵ Construction (including Development of Real Estate)
̵ Wholesale and Retail, Motor Vehicle Repair, Sale of Fuel
̵ Transportation and Storage
̵ Information and Communication
̵ Business Services
̵ Government Administrative Functions, Education, Health
̵ Other Service Activities

Main Activity Sub activity

Select one from the drop down list that will be Select one from the drop down list generated from the
generated by the industry selected main activity chosen.

About the kind of accident.

Select the kind of accident that best
describes the incident
Select one kind from drop down list
̵ Contact with electricity
̵ Contact with machinery
̵ Drowned or asphyxiated
̵ Exposed to explosion
̵ Exposed to fire
̵ Exposure to harmful substance
̵ Fall from height
̵ Injured by animal
̵ Lifting and handling injuries
̵ Physical assault
̵ Slip, trip, fall same level
̵ Struck against
̵ Struck by moving vehicle
̵ Struck by object
̵ Trapped by something collapsing
̵ Another kind of accident

If a fall from height, how high was the fall?       (in metres)

Work process involved in the incident Select one process from drop down list

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 ̵ Agricultural work, forestry, horticulture, fishing, work with
animals
̵ Cleaning – industrial or manual
̵ Commercial activity – buying, selling & associated services
̵ Construction – civil engineering, infrastructures, roads,
bridges, ports
̵ Construction – new building
̵ Construction – remodelling, repairing, extending, building
maintenance
̵ Demolition
̵ Maintenance, repair
̵ Monitoring, inspection
̵ Movement, including aboard transport
̵ Production, manufacturing or processing
̵ Service or assistance to the public
̵ Sport or artistic activity
̵ Storing, warehousing
̵ Teaching, training, office work
̵ Waste management, disposal, treatment
̵ Other processes not listed above

Main factor involved in the incident
Select one factor from drop down list
̵ Being caught or carried away by something (or by
momentum)
̵ Breakage, bursting or collapse of material
̵ Electrical problem, explosion or fire
̵ Kneeling, sitting or leaning on an object
̵ Lifting, carrying, standing up
̵ Loss of control of machinery, transport or equipment
̵ Overflow, leak, vaporisation or emission of liquid, solid or
gaseous product
̵ Pushing, pulling
̵ Putting down, bending down
̵ Shock, fright, violence, aggression
̵ Slip, stumble or fall
̵ Twisting, turning
̵ Walking on a sharp object
̵ Other cause not listed

Describe what happened

     

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About the injured person.
Title           Forename       Family name      

Address 1      
Address 2      
Address 3      
Town      
County      
Post Code       Phone number      

Gender Male Female Age      

Injured person’s employment status.
What is the injured persons occupation or job title?
     
Was the injured person
one of your employees? on a training scheme? employed by someone else?
on work experience? self-employed and at work? a member of the public
Details if the injured person was on a training scheme or employed by someone else
     

About the severity of the person’s injuries.

Was the injury fatal?
If no was the injury one of these as specified under RIDDOR

̵ bone fracture excluding finger, thumb or toe

̵ amputation of arm, hand, finger, thumb, leg, foot or toe
̵ blinding or permanent sight reduction
̵ crush injuries leading to brain damage or internal organ damage
̵ serious burns
̵ scalping requiring hospital treatment
̵ loss of consciousness caused by head injury or asphyxia
̵ injuries associated with working in an enclosed space leading to
hypothermia or heat-induced illness, resuscitation, hospitalisation for
over 24 hours
YES NO

If no, the injury prevented the worker from carrying out their routine work for more than 7 days YES
The injury was to a member of the public taken directly to hospital/injured on hospital premises YES
Injuries Select one from drop down list
̵ Amputation
̵ Loss of sight
̵ Fracture
̵ Dislocation without fracture
̵ Concussion and or internal injuries
̵ Lacerations and open wounds
̵ Contusions and bruising

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 ̵ Burns
̵ Asphyxia or poisoning
̵ Strains and sprains
̵ Superficial injuries
̵ Multiple injuries
̵ Electric shock
̵ Natural causes
̵ Other known injuries
̵ Other unknown injuries

Part of the body affected Select one from drop down list
̵ Eye
̵ Ear
̵ Other parts of face
̵ Head
̵ Several head locations
̵ Neck
̵ Back
̵ Several torso locations
̵ Finger or fingers
̵ Hand
̵ Wrist
̵ Upper limb
̵ Several upper limb locations
̵ Toe
̵ Foot
̵ Ankle
̵ Lower limb
̵ Several lower limb locations
̵ Several locations
̵ Unknown location

+++++

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