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SECTION 1Part A: About the accident / incident / near missPart B: About the injured person 1 On what date did the incident happen? 1 Full Name 2 At what time did the incident happen? 2 Contact telephone number 3 Where did the incident happen? 3 EmployeeStudentVisitor/public Other4 Job title / student category 4 Name of person reporting incident 5 Department / Area Part C: About the injury 5 Were there any witnesses? If yes, please give their names & departments 1 What was the injury? (e.g. fracture, laceration, burn etc.) 2 What part of the body was injured? 6 Was anyone injured?  YES NO If YES, go to part B. If NO go to part D3 Did the person.....  Become unconscious? YES NO  Need resuscitation? YES NO Remain in hospital for more than 24 hours? YES NO Any other useful information 4 What first aid treatment (if any) was given? 5 Name of the person who administered first aid  SECTION 1 continuedPart D: Describing what happened1 Give as much detail as you can. For example: The events that led up to the incident What you were doing at the time of the incident The name and type of any machinery involved The nature of the area housekeeping; spillage; lighting; obstacles; security; litter; noise; etc. The part played by the people involved The name and volume of any substance The position of people or objects in relation to the incident Other salient points  Signature of injured person / reporter of incident Print Name:Date: SECTION 2 (to be completed by the Head of Department)1 When did you first become aware of this incident? 2 What action has been taken or is being taken to prevent a similar incident? 3 If an injury occurred, how long is the injured person expected to be away from work?Days: _____ Weeks: _____ 4 On the day of the incident what was the injured persons  Expected hours of work?Actual hours of work? 5 Safety Representative informed?  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