ML83 Electronic Notification
About you - the person completing this report
Name
First Name
Last Name
Which Depot are you based at?
Garboldisham
Email
example@example.com
Date & Time on which you completed this form.
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Day
-
Month
Year
Date
Time
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Are you reporting an Incident, or Road Traffic Collision or Theft? NOTE: Road traffic collision notifications MUST be accompanied by Appendix C of the Accident Reporting Procedure - completed in full by our driver.
*
Incident
Road Traffic Collision
Theft
Complaint
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Position
Depot Manager
Admin
Planner
Director
Manager
Coordinator
HR
Finance
Workshop
Plant
HSEQ Manager
HSEQ Admin
Other / Unlisted
Phone Number
-
Area Code
Phone Number
Details of Person Involved in this incident
If this matter relates to theft of hired equipment - who was this on hire to at the time of the theft?
Type of Person
Employee
Contractor
Agency
Public
Visitor
Intruder
Name
First Name
Last Name
Age
*
Phone Number
-
Area Code
Phone Number
Job Title
*
Approx length of time in current role?
*
How many hours had the operative been working when this incident occurred?
*
Email
example@example.com
Address
Street Address
Street Address Line 2
City
County
Postal Code
Time of Incident
*
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
Date of Incident
*
-
Day
-
Month
Year
Date
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Details of Incident
Location of Incident
*
Our Drivers Vehicle Registration
*
Plant Number or Reg (Thefts)
Our Vehicle Type
*
Third Party Vehicle Registration
Local Speed Limit
Speed Traveling
Third Party Driver(s) Names
Third Party Drivers Contact Number
-
Area Code
Phone Number
Details of Third Party Insurers
Third Party Policy Number
Third Party Car make, model and colour.
Who was at fault for this collision?
Our Driver
Third Party
Shared Liability
Non Fault Incident
Select the type of injury
Slip,trip,fall
Manual Handling
Contact - Machine
Cut or Abrasion
Physical assault
Other
No Injuries Reported
What was involved
Cutting
Electricity
Explosion
Fall From Height
Fire
Chemical or Substance
Hot Material
Machinery
Manual Handling
Moving Vehicles
Other
Slip or Trip
Violence
Briefly describe the incident - including any equipment / processes being used / damage
Describe any circumstances that may have contributed to the incident.
How Many days did the employee take off as a result of this incident?
Police Incident Number
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Details of Injury
What type of Injury or ill health was sustained or suspected
Acute Illness
Amputation
Bruise / Graze
Cut
Burn
Dislocation
Electric Shock
Eye Injury
Fracture
Loss Of Consciousness
Muscular / Skeletal Injury
No Injury
Other
What part of body was injured?
Ankle
Arm
Back / Neck
Chest
Eye
Finger
Foot
Hand
Head
Knee
Leg
Shoulder
Stomach
No Injury
Toe Wrist
Did they need resuscitation?
Yes
No
Did they become unconscious?
Yes
No
Did they remain in hospital for more than 24 hours?
Yes
No
Don't Know
Did the injured person go directly to hospital from the incident scene?
Yes
No
Outcome of Incident
A Fatality
A Specified Injury or Occurrence
Accident preventing employee from working more than 7 days.
Accident involving member of public being taken to hospital.
Non Reportable.
Reportable Disease.
RIDDOR Dangerous Occurrence.
Unknown at Present.
Name of First Aider in attendance (if first aid provided)
Treatment Received
First aid & Returned to work.
Home.
Hospital.
Returned to work.
Not Required.
Witnesses
Enter details of any witnesses below.
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Environmental Conditions
What were the conditions like prior to the incident occurring e.g. noise, temperature, lighting, dust, fumes, weather, time of day.
Provide details of Training and Experience if this was an employee
Describe the level of supervision and safety management in force at the time of the incident.
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