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Accident Reporting Procedure Introduction This version of the Accident Pad (blue sheets) replaces the older (yellow) pads within the University as well as the Accident Books, which should by now have been returned to the Department of Risk, Safety and Health for safe disposal. If you have any questions please refer to the reporting procedures below, or alternatively, contact the Department of Risk, Safety & Health on extension 1265 or via email to rsh@wlv.ac.uk. What should I report? In the event of any of the occurrences shown below, please complete a form from this pad and return it to the Department of Risk, Safety and Health. A photocopy of this form should be sent to the line manager / tutor of the injured person. In order to comply with the Data Protection Act 1998, personal details entered in accident pads must be kept away from public view. All copies should be kept in a secure location. This procedure includes contractors, visitors and members of the public who do not have line managers/tutors on site. All accidents should be reported to the Department of Risk, Safety and Health immediately but those affecting contractors should also be reported to their employer as soon as possible. Please report any of the following occurrences on the accident report form: • • • • • • • Any accident regardless of severity or activity at time of the occurence; Injury to person or persons; Near misses - any occurence where an accident/injury has been narrowly avoided; Death of person or persons due to an accident; Physical abuse; Verbal abuse; and Threatening behaviour. In all cases, if the injury / near miss was caused by faulty equipment / damaged property (e.g. loose floor tiles) then the relevant University department e.g. Property Services, Maintenance, Campus Operations must be informed immediately so that repairs can be made. In most cases calling the Facilities helpline on extension 1111 can do this. The Department of Risk, Safety & Health is responsible for reporting major injuries and incidents to the Health and Safety Executive (HSE) under Reportable Injuries, Diseases and Dangerous Occurences Regulations (RIDDOR). It is therefore vital that the following should be reported to the Department of Risk, Safety & Health immediately: • The death of any person as a result of an accident arising out of or in conjunction with work. • Major Injuries including any fracture, other than to the fingers, thumbs or toes, any amputation, dislocation of the shoulder, hip, knee or spine, loss of sight (whether temporary or permanent), a chemical or hot metal burn to the eye or any penetrating injury to the eye, any injury resulting from an electric shock or electrical burn (including any electrical burn caused by arching or arching products) leading to unconsciousness or requiring resuscitation or admittance to hospital for more than 24 hours. • Any other injury leading to hypothermia, heat-induced illness or to unconsciousness, requiring resuscitation or requiring admittance to hospital for more than 24 hours. • Loss of consciousness caused by asphyxia or by exposure to harmful substance or biological agent. • Acute illness requiring medical treatment or loss of consciousness from the absorption of any substance by inhalation, ingestion or through the skin. • Acute illness which requires medical treatment where there is reason to believe that this resulted from exposure to a biological agent to toxins or infected material. • Dangerous occurrences including collapse, overturning or failure of any load bearing part of any lift or lifting equipment, or electrical short-circuit or overload leading to fire or explosion. • This list is not exhaustive. A full list of Dangerous Occurrences will be found in Schedule 2 of RIDDOR 1995. You can also find further information at: http://www.riddor.gov.uk/info.html Report of an Accident / Injury / Assault to an Employee / Non-Employee Please complete all sections of the form and use a separate form for each incident 1.Surname………………………………… Forename(s)……………………………………………………..………………… Address:..…………………………………………………………………………………….…………………………. Telephone Number:..………………………………………. Age ……………… Male □ Female □ 2. Date of accident ………………………………Time (24 hour clock e.g. 14:20)……………….. ………………………………… Precise address and location of accident:..……………………………………………………………………………………… How would you describe the accident: Physical Assault □ Threatening Behaviour □ Verbal Abuse □ Other □ 3. Please give a full account of the accident, including acts of violence. Explain what happened and what the injured person was doing. If a fall from height, please state height. If necessary, please provide a sketch on a separate sheet. ……………………………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………………………… 4. Details of any injuries sustained (e.g. laceration of the 1st finger on right-hand, scald to left foot, etc…) ……………………………………………………………………………………………………………………………………………………… ……………………………………………………………………………………………………………………………………………………… 5. Did the injured person Become unconscious □ Need resuscitation □ How would you describe the condition of person at the time of the incident (e.g. rational, shocked, traumatised.) …………………………………..………………………………………………………………………………………………. 6. Was the injured party treated at hospital? Yes □ No □ If Yes, which hospital? ………………………………………… Were they detained in hospital over 24 hours? Yes □ No □ 7. To whom was the accident / injury reported? Name:..……………………………………………………. Position:……………………………………………………………… 8. Names and addresses of witnesses: Name..………………………………………………………. Name..………………………………………………………………….. Address …………………………………………………… Address..………………………………………………………………. Tel:..……………….………………………………………… Tel:..……………………………………………………………………. 9. Is the injured person: A University Employee □ Contractor □ Member of the public □ Postgraduate □ Undergraduate □ Other □ (Please specify) …………………………………... 10. If the person involved in the incident is a University employee or student, please complete the following: Job title (for students please indicate if UG or PG)……..…………..………………………………………………………………..… School/ Department:……………………………………………………………………………………..………………..………….………. Normal base of work or study e.g. City Campus South:……………………..…………………………………………………………. 11. If the person involved in the incident is NOT a University employee or student, please complete the following: Job title:.………………………….…………………………………………………………………………………………………………..… Employer details:……………………………………………………………………………………..………………..………….………. Reason for visit to the site of the incident:……………………..…………………………………………………………. 12. In the event of an injury has the injured person’s employer / guardian or other appropriate contact been informed? Yes □ No □ If Yes, who was notified? ………………………………………………………………………………………… By whom………………………………………….. Date……………………………….. Time…………………………………….. 13. Did the incident happen at the place where the person was authorised to be for their work? Yes □ No □ If NO, why was the individual there?……………………………………………………………………………. Was the person undertaking duties authorised or permitted as part of their work? Yes □ No □ Purpose of the activity………….……………………………………………………………………………….… 14. Was the incident subject to police investigation? Yes □ No □ If yes, which station? ……………………….……… Name/rank/number of the Officer dealing………………………………….. 15. If the incident was as a result of a hazard, what immediate action has been taken to remove hazard? ………………………………………………………………………………………………………………………………………………….… Time / Date of hazard removal………………….………….……………Removal undertaken by…………………………………… 16. Is the accident / injury RIDDOR reportable (see explanation sheet in accident pad) Yes □ No □ 17. If faulty equipment / damaged property was found at the scene of the incident has this been reported to the relevant University Department? Yes □ No □ If Yes, who was notified? ………………………………By whom ……………………………… Date and time……………………… 18. Has a copy of this form been sent to the appropriate Line Manager / Dean / Director? Yes □ No □ If Yes, who was form sent to?…………………………………………………………………………………… 19. Number of days the person involved in the incident is likely to be absent from work, including weekends: None □ 3 days or less □ 4 days or more □ Return to work date (RSH use only): 20. Signature of person completing this form: Signature…………………………………………. Date ………………………… Name (BLOCK LETTERS)………………………………………………. Position………………………………….……………… 21. Monitoring: White British □ White Irish □ White Other □ (specify)…………………………………….…………….. White / Black Caribbean □ White / Black African □ White / Asian □ Mixed Other .……………………………….. Indian □ Pakistani □ Bangladeshi □ Caribbean □ African □ Chinese □ Other □………………………… Does the person involved in this incident consider themselves in any way disabled? Yes □ No □ PLEASE RETURN THIS FORM TO THE DEPARTMENT OF RISK, SAFETY AND HEALTH AS SOON AS POSSIBLE AFTER THE ACCIDENT / INJURY / NEAR MISS, WITH A COPY TO THE RELEVANT LINE MANAGER / DEAN / SERVICE DIRECTOR