injury or dangerous occurrence report form

1
Appendix A
HERTFORDSHIRE COUNTY COUNCIL INJURY OR
DANGEROUS OCCURRENCE REPORT (IDOR) FORM

DEPARTMENT____________________
PERSON COMPLETING REPORT NAME ADDRESS OF
ESTABLISHMENT, NAME ______________________
________________________ OFFICE, DEPOT
ETC. _____________________________________
____________ POSITION _____________________
______________ _____________________
___________________ TEL NO. EXT.
______________________________ DEPT
LOCATION
DATE CODE
CODE
SIGNATURE. ___________________

OFFICIAL USE
OFFICIAL USE
TYPE OF REPORT (please tick as
appropriate) PERSON IN CHARGE OF
ACTIVITY AT TIME OF INCIDENT (if
different from above)

1. PERSONAL
INJURY 2. NOTIFIABLE DANGEROUS
OCCURRENCE NAME
____________________________________ 3.
OTHER - NEAR MISS Report 2 also
requires F2508 to be completed for HSE
POSITION _____________________________________
Refer to departments Safety Statements and notes
of guidance for local procedures.
DETAILS OF PERSON INJURED/INVOLVED (please tick
as appropriate) (ONE PERSON PER
FORM) SURNAME ______________________________
HCC EMPLOYEE STUDENT/PUPIL O
THER NAMES _________________________
CONTRACTOR RESIDENT AGE ___________
SEX M F
VISITOR/MEMBER OTHER CLIENT
OF PUBLIC JOB TITLE/RANK _______________________
VOLUNTARY ACTIVITY AT TIME
WORKER HCC PAY NO OR FIRE OF
INCIDENT RESCUE UER NO.
_________________________________________________

OCC.
CODE ADDRESS OF NON-EMPLOYEE
___________________________________
________________________________ ACTIVITY
CODE __________________________ WAS
ANYBODY ELSE INVOLVED? YES
NO DETAILS OF INCIDENT EXACT LOCATION
_____________________________ DATE
TIME
_______________________________________ OCCURRED
_________AM/PM
__________________________________________________
_________ REPORTED
_________AM/PM FACTUAL DESCRIPTION
OF EVENTS CIRCUMSTANCES (IF FALL OF PERSON OR
MATERIALS GIVE HEIGHT OF FALL)
(Attach additional
sheets if necessary and sketchplan where
appropriate) PROTECTIVE CLOTHING/EQUIPMENT
USED PLANT/EQUIPMENT/VEHICLES INVOLVED

MATERIALS/SUBSTANCES/CHEMICALS INVOLVED(NAME,TYPE,
PARTS,REG.NUMBER,WHETHER IN MOTION) (TYPE,TRADE
NAME,CHEMICAL DESCRIPTION)

AGENT CODE



OFFICIAL USE
OFFICIAL USE
OFFICIAL USE
OFFICIAL USE
2
DETAILS OF INJURY AND TREATMENT
Was injury sustained? YES
NO If YES, give details of
nature, site and extent _________________________
___________________________________________
RISK CODE _____________________________________
_______________________________ BODY
CODE TYPE OF TREATMENT HOSPITAL
DOCTOR FIRST
AID REST
NONE DETAILS OF TREATMENT
_________________________________________________







INJURY CODE
OFFICIAL USE
OFFICIAL USE
OFFICIAL USE
NAME ADDRESS OF HOSPITAL/DOCTOR (If
appropriate) WITNESS/ES _________________________
___________________________ NAME
__________________________________ ______________
______________________________________ ADDRESS
_______________________________ ____________
_____________________________ If an employee, has
the injury resulted in absence (ATTACH
STATEMENT) from work? YES NO
HSE STATUTORY
REQUIREMENTS If yes, did he/she do any work on
the day of Is incident notifiable to HSE? (See
Departmental the incident after it happened? YES
NO Safety Arrangements)
YES NO IF YES What time did
he/she stop work? _______________am/pm
HSE notified by phone? YES
NO Anticipated duration of absence
_______________ days HSE form F2508 sent?
YES NO BY NAME
DATE
IF THIS FORM HAS NOT BEEN COMPLETED BY THE
MANAGER, MANAGER MUST SIGN HERE TO INDICATE THAT
THEY ARE AWARE OF ACCIDENT/INCIDENT DETAILED
OVERLEAF AND ABOVE. Managers Name Signature
Date INVESTIGATION - THIS SECTION MUST BE
COMPLETED


NB All
Accidents/Incidents need to be investigated to
determine their cause and prevent recurrence.
Please refer to Departmental Policy
and Procedures and/or the County Policies and
Procedures Guidance Handbook. Give details of
any
discrepancies found in the information given and
any action taken to determine the cause or
prevent recurrence.
(Additional sheets may be submitted with this
form) Has any previous complaint/report relating
to the incident, or its cause been made?
YES NO If YES, please give
details Investigating Officer NAME

SIGNATURE
POSITION
TEL NO.
DATE Completion of this form does not
constitute a claim against the County Council.
NOTE This form should be completed as soon
as possible after the accident/incident and
processed in accordance with your departmental
arrangements and the original sent to the CSF
HEALTH AND SAFETY TEAM, ROOM 159, COUNTY HALL,
HERTFORD SG13 8DF