Personal Injury Report Form, Notes on Completion. Purpose 2. Strategic Aims 2. Sections 1 9 guidance 2-5

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1 Brigade Order Health and Safety Brigade Order 9 Part 3 Section Title Personal Injury Report Form, Notes on Completion Contents Page No. Purpose 2 Strategic Aims 2 Introduction 2 Sections 1 9 guidance 2-5 Appendix A Personal Injury Report form () Roles, Responsibilities and Review The Head of People Development and Safety is responsible for ensuring this Order is implemented across the Service. The Health and Safety Officer will be responsible for the day to day operation of the Order. The Health and Safety Officer will review this Order every 3 years, when new legislation arises or as and when organisational needs require. Reference Author Status Date Page HS9PT3 HSO Amended 03/13 1 of 18

2 Health and Safety 9 Part 3 Personal Injury Report Form, Notes on Completion Purpose This Order is designed to provide guidance for the completion of Personal Injury Report form. Strategic Aims Aim No. 3. To reduce the number of fire related deaths and serious injuries Introduction The Personal Injury Report form (see Appendix A) has been designed to guide personnel through the various stages of reporting and investigating so that all the issues relevant to accidents are raised and recorded. It is the responsibility of the Line Manager (in the case of Minor Injury) and Investigating Officer to ensure that it is properly completed. In all cases Section 1 of the form should be completed, and forwarded to the Health and Safety Officer as soon as possible and in any case within 24 hours. The guidance detailed below refers to those sections of the form where the information required is not obvious from the form. Section 1 guidance This section is to be completed by the injured person or their Line Manager. Sub-section A Who was injured? Complete as much of this as possible but do not unduly delay sending the document if some of the information (for example, age) is not readily available. Sub-section B What were the injuries? State what the injury is, what part of the body is injured and the extent of the injury. For example: or large area of grazing on the left shoulder two 50mm long cut to the outer thigh Sub-Section C When and where did it happen? Date and time - State the date and time when the accident occurred. Name of site - Give an address, name of road, or name by which the site is known. Precise location - State name of room and/or distance and direction from a fixed point. Reference Author Status Date Page HS9PT3 HSO Amended 03/13 1 of 5

3 Examples: or name of site J J Smith Limited, 26 High Street, Hilltown precise location Machine Shop close to entrance door name of site M54 Motorway precise location Hard shoulder, East-bound carriageway three, hundred meters east off Junction 5. Sub-Section D History Report on the hours that the injured party had been working prior to the incident and whether there had been any prior ailments/injuries reported. Sub-Section E What action was taken after the incident? Complete each section as fully as possible. Sub-Section F - Report on the circumstances of the incident Give as much detail as possible on the circumstances of the accident Sub-Section G Minor Injury only Complete this section in accordance with Brigade Order Health and Safety 9 Part 4 giving details of any findings as to the cause of the accident and what actions need to be implemented to prevent recurrence. Note: If it is a Minor Injury the Line Manager should only complete Section 1; then forward, along with completed BI 510, to the Health and Safety Officer / Operational Performance and Safety Officer, Brigade HQ, Shrewsbury. Section 2 to be completed by the Health and Safety Officer This section is to be completed by the Health and Safety Officer. Section 3 guidance To be completed by the Investigating Officer, all details should be completed as fully as possible within 3 weeks of the accident. Sub-Section A Investigating Officer s Report Service no., name and role are those of the Investigating Officer. Sub-Section B Activity Did the accident occur as part of a training, operational or some other activity? Reference Author Status Date Page HS9PT3 HSO Amended 03/13 2 of 5

4 Sub-Section C Incident Details Enter a brief description of the accident and any condition that might have attributed to it occurring. Sub-Section D Procedures Has a risk assessment been completed for this activity, if so what was the reference number (prefaced with Shropshire FRS in top right hand corner of FB152). If there is no reference number please enter title and date of risk assessment and attach a copy to the Accident Report. Sub-Section E Contamination by Hazardous or suspected Hazardous Material Enter details if any contamination occurred; type, identification numbers, areas affected and length of exposure Sub-Section F Defect/Failure of Equipment/Uniform? Tick Uniform, Equipment or Neither as appropriate. If Equipment is ticked, complete sections a) to g) as fully as possible, completing the table. Tick only those items Clothing and Equipment Used at the Time of the Injury relevant to the accident. For instance Boots (rubber) may be appropriate if they were being worn by someone who slipped. Flash Hood would probably not be appropriate to someone who had cut their hand Sub-Section G Diagram On the diagram cross or shade the affected area or areas of the body injured. Sub-Section H List of Witnesses Enter the details of any witnesses. In the case of Service witnesses, enter Service No, Station, Department or Watch. If a statement has been taken, tick the appropriate box and submit the statement with the accident report. If there are more witnesses than spaces provided, add the details to a separate sheet and attach it to the accident report. Sub-Section I Medical Treatment This section deals with the treatment given in the initial and progressive stages of injury. The section must be answered in as much detail as possible and as far as is appropriate given the nature of the casualties injuries. Sub-Section J Individual Development Record Enter details of when the injured person last completed the activity and whether it is considered that person was competent at the time of the accident. Reference Author Status Date Page HS9PT3 HSO Amended 03/13 3 of 5

5 Sub-Section K Sketch Plan of the Site A sketch of the accident site should be made. Sub-Section L Photographic Evidence If relevant, photographic evidence should be attached here. Sub-Section M Conclusions of the investigation As far as possible, state the cause of the accident. Phrases such as this was a genuine accident should be avoided. Sub-Section N Immediate causes of the incident Identify any unsafe acts or conditions contributing to the incident. Sub-Section 0 Secondary causes of incident Identify any possible human, organisational or systems of work that may have contributed to the incident. Sub-Section P Recommendations Provide any recommendations and/or learning points to prevent recurrence. Sub-Section Q Remedial Action Taken Has any remedial action been taken to reduce the likelihood of the accident reoccurring? Section 4 Principal Officer initiating investigation This section should be completed by the Officer who instigated the investigation. This will not be the Investigating Officer unless the injury is classed as a Minor Injury. Section 5 to be completed by Head of People Development and Safety This section is to be completed by the Head of People Development and Safety Section 6 to be completed by the Health and Safety Officer This section is to be completed by the Health and Safety Officer Section 7 to be completed by the Action Implementation Officer This section is to be completed by the Action Implementation Officer Reference Author Status Date Page HS9PT3 HSO Amended 03/13 4 of 5

6 Section 8 to be completed by the Health and Safety Officer This section is to be completed by the Health and Safety Officer/Operational Performance and Safety Officer Section 9 Human Resources This section should be completed by a Human Resources Officer. Reference Author Status Date Page HS9PT3 HSO Amended 03/13 5 of 5

7 Report N o Personal Injury Report Section 1. To be completed by the injured person s Line Manager Who was injured? A.1 Surname: A.2 Forenames: A.3 Date of Birth: / / A.4 Gender: A.5 Age: A.6 Address: Please tick: A.7 Employee: A.8 Visitor: A.9 Contractor: A.10 Other: (Please specify) If the person is an employee, please give the following information: A.11 Role: A.12 Payroll No.: A.13 Nat. Ins.: What were the injuries? (Include nature, site, and extent of the injuries) When and where did the incident happen? C.1 Date of incident: / / C.2 Time of incident: C.3 Incident No.: C.4 Name of site: C.5 Precise location: (E.g. Name of room) C.6 Was the person on duty: Yes/No D. History: D.1 How many hours had the employee been working (all employment) prior to the incident? D.2 Had the employee reported any recent/previous ailment/injury prior to this injury? Yes/No Hrs Min E. What action was taken after the incident? E.1 To whom was the incident reported? E.2 Date reported: / / E.3 Time: E.4 Was First Aid rendered? Yes/No E.5 If Yes, by whom: E.6 Did a doctor/paramedic attend? Yes/No E.7 If Yes, give details: E.8 Did the injured person attend hospital/gp? Yes/No E.9 If Yes, give details: E.10 If Yes, what treatment was given? HS9PT3 AA /12

8 F. Circumstances of the incident- including How did the injury happen? (What was the injured person doing at the time of the incident) Minor Injury only Brigade Order Health and Safety 9 Part 4 (All other injuries go to Section 3) If this is a Minor Injury the Line Manager should Only complete Section 1; then forward, along with the completed BI510, to the Health and Safety Officer / Operational Performance and Safety Officer, Brigade Headquarters, Shrewsbury within 24 hours. G. Minor Injury only: G.1 Line Manager s findings as to the cause of the incident: G.2 Line Manager s action to prevent recurrence: Signed: Print name: Date: / / HS9PT3 AA /12

9 Section 2. To be completed by the Health and Safety Department A. Minor Injury: A.1 Date of entry in accident book BI510: / / Please Tick: B.1 RIDDOR - Major Accidents B.2 RIDDOR - Over 7 Day Accidents (Fatality, specified Major Injury) B.3 RIDDOR - Dangerous B.4 Minor injury Occurrences B.5 Dangerous Occurrence B.6 KPI Other B.7 KPI Manual Handling B.8 KPI Slips, Trips & Falls B.9 KPI Hit something Moving, flying or falling object B.10 KPI Hit something fixed or stationary B.11 KPI Burn - Operational B.12 KPI Burn - Training Follow up actions: C.1 Any follow up actions: C.2 Date completed: D. Additional ( ) pages attached: Yes/No If Yes please list: Signed: Print Name: Date: / / HS9PT3 AA /12

10 Section 3. To be completed by the Investigating Officer (To be completed within 3 weeks of the reported incident date) A. Investigating Officers report: A.1 Service No.: A.2 Name: A.3 Role: A.4 Date of investigation: / / A.5 Date of incident: / / A.6 Time of incident: A.7 Injured person interviewed: Yes/No A.8 Witness/witnesses interviewed: Yes/No A.9 Incident location: B. Activity: Please tick: B.1 Training B.2 Operational B.3 Other B.4 Details C. Incident details: (Description including light/weather conditions) D. Procedures: D.1 Has a Risk Assessment been carried out for the activity at this location? Yes/No D.2 If Yes, please provide Reference Number and date of last review: D.3 Are there Safe Working Procedures in place? (SIP, SOP, Brigade Order, GRA) Yes/No D.4 If Yes, please provide details: D.5 Did the employee fail to follow accepted procedures? Yes/No D.6 Did the employee work beyond their capabilities? Yes/No D.7 Did the workplace or premises involved contribute to the incident? Yes/No D.8 Did the equipment or substances being used contribute to the incident? Yes/No D.9 Did the process or procedures adopted contribute to the incident? Yes/No D.10 Did the people involved contribute to the incident? Yes/No D.11 If Yes to D5 D10, please provide details: E. Contamination by hazardous or suspected hazardous material: Yes/No E.1 Substance name: E.2 Classification of hazard: e.g. Irritant, harmful etc. E.3 Substance identification number: E.4 Part of body contaminated: E.5 How contaminated: (Please tick all that apply) i. Skin Contact ii. Inhalation iii. Injection iv. Ingestion E.6 Length of exposure: Hours Minutes HS9PT3 AA /12

11 F. Defect/Failure of Equipment or Uniform: F.1 Did the injury result from any defect in or failure of equipment or uniform? Yes/No F.2 Uniform: F.3 Equipment F.4 What was the uniform or equipment? F.5 What was the nature of the defect or failure? F.6 Date the equipment/uniform was last examined /tested? / / F.7 What were the results of the examination/test? F.8 Who carried out the last examination/test? F.9 If the injury is the hand or wrist, were Service Yes/No F.10 Detail type: gloves worn? F.11 What equipment was being used at the time of the injury(ies)? F.12 Please tick the appropriate answers for each piece of equipment or uniform used. Where known please enter the age of the equipment or uniform? Clothing Worn Yrs Mths Clothing Worn Yrs Mths i. Helmet Rubber fire boots iii. Flash Hood Gloves v. Ear protection Breathing apparatus vii. Goggles / Safety Gas tight suits ix. Specs T Shirt xi. Visor up / down Shirt xiii. Tunic Overalls xv. Fluorescent Jacket Trousers / Skirt xvii. Over trousers Socks xix. Leather fire boots Shoes xxi. Other (Detail) HS9PT3 AA /12

12 G. Injury diagram: Please indicate on the below diagrams where the injury(ies) occurred: For less widespread injuries use a cross. For more widespread injuries please shade the affected areas. A Forehead B Ears C Eyes D Nose E Cheeks F Chin G Hair or Scalp H Shoulders I Upper arms J Elbow(s) K Forearms L Wrists M Hands N Upper torso O Lower torso P Buttocks Q Thighs R Knee(s) S Lower leg T Ankles U Feet V Neck W Mouth HS9PT3 AA /12

13 H. List of witnesses: (continue on separate sheet if necessary) H.1 Name: H.2 Service No.: H.3 Station: H.4 Watch/Dept: H.5 Address: H.6 Statement taken: Yes/No H.7 Attached: Yes/No H.8 If No please give reason: H.9 Name: H.10 Service No.: H.11 Station: H.12 Watch/Dept: H.13 Address: H.14 Statement taken: Yes/No H.15 Attached: Yes/No H.16 If No please give reason: I. Medical treatment: I.1 Was First Aid rendered? Yes/No I.2 If yes what was the First Aid treatment given? I.3 Who administered it? I.4 If Service Personnel administered First Aid, are they Service First Aid trained? Yes/No I.5 Did the injured person attend hospital? Yes/No I.6 Who examined them at the hospital? I.7 Length of time they underwent treatment at hospital (approximate hours): I.8 What treatment was given? J. Individual Development Record: If the incident was related to operational or training activities please complete the following: J.1 Was the activity previously recorded in the persons IDR? Yes/No J.2 Date the activity was last undertaken: / / J.3 Was the person competent? Yes/No J.4 If No what additional steps had taken place/were planned: HS9PT3 AA /12

14 K. Sketch plan of the incident site: L. Photographic evidence: L.1 Were photographs taken? Yes/No L.2 Attached: Yes/No If No please give reason: M. Conclusions of the investigation: N. Immediate causes of incident - what unsafe acts or conditions caused the event? N.1 Unsafe Act: (Any task or activity conducted that caused the incident, e.g. operating equipment incorrectly or lack of or improper use of PPE). N.2 Unsafe Condition: (Any condition in the workplace that caused property damage or injury, e.g. excessive noise or defective tools/equipment). HS9PT3 AA /12

15 O. Secondary causes of incident - what human, organisational or systems of work caused the incident? P. Recommendations: Q. Remedial action taken: Signed: Print name: Date: / / HS9PT3 AA /12

16 Section 4. To be completed by the Principal Officer who initiated the investigation A. Principal Officer initiating investigation Please tick: A.1 I am not satisfied that this information provides an accurate and complete record of the incident and its cause and require the following information: A.2 I am satisfied that this information provides an accurate and complete record of the incident and its cause. No further investigation is required. B. I note the recommendations and remedial action in Section 3 and require the following action(s) to be implemented: Action(s) Action Implementation Officer Date completed ( * ) *To be completed by the Action Implementation Officer I believe that this will reduce as far as practicable, a recurrence of the incident. Signed: Print name: Date: / / Section 5. To be completed by the Head of People Development and Safety Head of People Development and Safety: Additional comments: Signed: Print name: Date: / / HS9PT3 AA /12

17 Section 6. To be completed by the Health and Safety department Documentation: A.1 Date of entry in Accident Book BI510: / / A.2 Date F2508 sent to Enforcing Authority: / / A.3 Date received by HSO: / / Please Tick: B.1 RIDDOR - Major Accidents B.2 RIDDOR - Over 7 Day Accidents (Fatality, specified Major Injury) B.3 RIDDOR - Dangerous B.4 Minor injury Occurrences B.5 Dangerous Occurrence B.6 KPI Other B.7 KPI Manual Handling B.8 KPI Slips, Trips & Falls B.9 KPI Hit something Moving, flying or falling object B.10 KPI Hit something fixed or stationary B.11 KPI Burn - Operational B.12 KPI Burn - Training Follow up actions: C.1 Any follow up actions: C.2 Date completed: D. Additional ( ) pages attached Yes/No If Yes please list: Signed: Print name: Date: / / Section 7. To be completed by the Action Implementation Officer Action Implementation Officer: A.1 I am satisfied that all follow up actions and recommendations have been implemented and I have completed section 4 (*date completed). A.2 Additional comments: Signed: Print name: Date: / / HS9PT3 AA /12

18 Section 8. To be completed by the Health and Safety department Health and Safety Officer / Operational Performance and Safety Officer A.1 I am satisfied that all follow up actions and recommendations have been completed. A.2 Additional comments: Signed: Print name: Date: / / Section 9. To be completed by the Human Resources Department A Human Resources A.1 Report(s) placed on EPR: Yes/No Signed: Print name: Date: / / Any personal data entered on this form may be held on computer file. HS9PT3 AA /12