Customer Accident Incident Report

Details of Affected Person or Near Miss (This form incorporates a register of injuries) Nature of Incident: Injury Near Miss Property Damage Other (Please Specify) Other: BRC Recruitment to Complete: Circle the appropriate type: Permanent Employee Temporary Employee Name: Position: Address: Site Address: Contact Tel: Company Name: Mobile Tel: Client Name: Emergency Contact Name and Tel: Incident Details Permanent or Temporary Employee to complete (BRC Recruitment Representative to assist where required): Describe exact site location: Describe sequence of events leading to Incident: Were there any Witnesses to the incident Name: Contact: Name: Contact: Injury Details Temporary or Permanent Employee to complete (BRC Recruitment Representative to assist where required): Nature of Injury Sprain / Strain Bruising Concussion Open Wound Fracture Dislocation Burns / Scold Exposure to Elements Exposure to substance Skin rash Respiratory Irritation Hearing Loss Pain / Tenderness Whip lash Crush Injury Swelling Other (Specify): Part of body Injured Part of Body Side of body Region Internal or External Head Left Right Back Front Internal External Face Left Right Nose Mouth Jaw Internal External Eye Left Right Sighted Affected Y N Internal External Torso Left Right Upper Lower Internal External Back Left Right Upper Lower Internal External Arm Left Right Upper Lower Internal External Hand Left Right Upper Lower Internal External Leg Left Right Upper Lower Internal External Foot Left Right Upper Lower Internal External Other Left Right Upper Lower Internal External Other Please describe Note: Refer to below or Incident Reporting and Investigation Procedure PRO 09 for reportable incidents..