Burton and South Derbyshire College
incident report
20/04/2024 08:41:05

(All fields with a * must be completed.)

REPORT DETAILS

*Your name :
*Your department :
*Your role/title :
*Incident date :
*Incident time :
:
*Incident location :
*Incident type :  
*Incident Category Type :
No. of witnesses :
Witness names :
*Entities Informed :

PERSON AFFECTED

*Full name :
*Role :
Dept :
*Gender :
*Nature of Injury :
No injury
Abrasion
Bruise
Concussion
Cut/Laceration
Crushing/Crushed
Fracture
Puncture
Hearing
Sprain/Strain
Dislocation
Burn
Heat Injury
Cold Injury
Foreign body
Poison/Chemical
Dermatitis
Loss of Consciousness
Occupational Illness
DSE Injury
Amputation
Death

Other injury:
*Area(s) affected : (please click on the text links or area on the body map)
Right ear
Right eye
Right shoulder
Right upper arm
Right elbow
Right forearm
Right wrist
Right hand
Right fingers
Right thumb
Right hip
Right thigh
Right knee
Right lower leg
Right ankle
Right foot
Right toes
Right sole
None
Head top front
Head back
Face
Throat
Neck
Chest
Abdomen
Groin
Upper back
Middle back
Lower back
Buttocks
Left ear
Left eye
Left shoulder
Left upper arm
Left elbow
Left forearm
Left wrist
Left hand
Left fingers
Left thumb
Left hip
Left thigh
Left knee
Left lower leg
Left ankle
Left foot
Left toes
Left sole
If the injury was to a different area please state :
*Action required :
*PPE correctly used? :
*IF this person left the area : Destination :
Time departed
:
Affected person's address :

Affected person's phone number :

Parent / Carer / Next of kin contact :

(You can upload photos after submitting this report)


INCIDENT DESCRIPTION

*Describe the incident (in detail)

 

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