Health and Safety
Health and Safety at Work etc Act 1974
The Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 2013
Report of an injury
About you and your organisation
*Your Phone No
Address Line 1
(eg building name)
Address Line 2
Address Line 3
*Did the incident happen at the above address?
Page 1 of 5
About where the incident happened
*Where did the incident happen?
Elsewhere in your organisation
At someone else's premises
In a public place
Details of where the accident happened (if the address is not known)
Page 2 of 5
About the incident
(24 hr clock)
In which local authority did the incident occur?
Please refer to the help for guidance on the local authority
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)?
About the kind of accident
*Select the kind of accident that best
describes the incident
Kind of accident help
on the Kind selected)
If a fall from height, how high was the fall?
(to the nearest metre)
*Work process involved in the incident
on the Process selected)
*Main factor involved in the incident
Main factor help
(provides help on the main
*Describe what happened
(give as much detail as you can, including i) the events that led to the incident ii) the operation
or activity in progress. Describe any action taken to prevent similar incidents occurring).
Page 3 of 5
About the injured person
Injured person's employment status
*Was the injured person:
one of your employees?
on a training scheme?
employed by someone else?
on work experience?
self-employed and at work?
member of the public?
students, customers, patients)
Details if the injured person was on a training scheme/employed by someone else
*What was the person's occupation or job title?
Page 4 of 5
About the person's injuries
*Part of the body
*Did the person
as a result of their injury or injuries?
Please refer to the help for guidance on severity of injury.
Please check your email address below. Ensure that you change if incorrect as this is the email address that
your acknowledgement and a copy of the form will be sent to.
Page 5 of 5
If no, the injury prevented the worker from carrying out
their routine work for
more than 7 days
*If the person
die, did they sustain one of the
The injury was to a
member of the public
taken directly to hospital/injured on hospital premises
About the severity of the person's injuries
(provides help on the injuries selected)