HSE Logo

Health and Safety

Executive

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

(eg building name)

(eg street)

(eg district)

*Did the incident happen at the above address?

Page 1 of 5


HSE Logo

Health and Safety

Executive

Report of an injury

About where the incident happened

*Where did the incident happen?

(eg building name)

(eg street)

(eg district)

Page 2 of 5


HSE Logo

Health and Safety

Executive

Report of an injury

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

What type of work was being carried out (generally the main business activity of the site)?

About the kind of accident

Page 3 of 5


HSE Logo

Health and Safety

Executive

Report of an injury

About the injured person

(eg building name)

(eg street)

(eg district)

*Gender

Injured person's employment status

*Was the injured person:

Page 4 of 5


HSE Logo

Health and Safety

Executive

Report of an injury

About the person's injuries

*Did the person die 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 or

*If the person did not die, did they sustain one of the injuries listed?

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

Online
Offline