The Henry Cort Community College

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Accident report form

This form must be completed immediately following the accident. The form will be submitted to hns@henrycort.org. Should you require further information or advice, please contact the Health and Safety team: hns@henrycort.org.

Details of person(s) involved

First name* Surname*

Are they a...*Member of staffStudent

Was anyone else involved?*YesNo

If yes, please give names and relation to the incident.

Did the incident happen at college?*YesNo

Type of school: Secondary
Name of premises: The Henry Cort Community College
Town/City: Fareham
Postcode: PO15 6PH
Department which manages site on which the incident took place: Children's Services
Area: Fareham

Where on the premises did the incident take place?* Date of incident* Time of incident*

Type of incident you are reporting

Type of incidentAccident - something that resulted in injuryRoad traffic accident - a road traffic accident / incident that has resulted in injuryNear miss - something which did not cause harm but could have doneOccupational ill health - a range of specific illness or diseases that can be caused by work as defined in reporting of injuries, diseases and dangerous occurrences regulations (RIDDOR) 2013Dangerous occurrence - a specific reportable event as defined in the reporting of injuries, diseases and dangerous occurrences regulations (RIDDOR) 2013Violence and aggression - any incident in which a person is abused, threatened or assaulted in circumstances relating to their work

Kind of incident

Description of what happened

Was there an injury?*YesNo

What was the main injury/injuries?AmputationAsphyxia strangulationBite, stingBreak, fracture, crackBruising. swelling, hematomaBurns - chemical, coldBurns - heatCut, graze, scratchElectric shock burnHypothermiaInternal injuriesNeedle stickPartial/full loss of sightShock, emotional traumaSprain. strain, twist, dislocation

What part of the body was affected?EyeMouthOther parts of faceHeadNeckChest / upper bodyBackLower bodySeveral torso locationsFinger or fingersHandWristUpper limbSeveral upper limb locationsToeFootAnkleLower limbSeveral lower limb locations

Description of injury Did the injury include any of these specific injuries?

Result of injuryNo treatmentFirst aidMinor injurySpecified injuryTaken to hospital1-7 days absenceOver 7 days absence

Was the injured person taken from site of accident to hospital?YesNo

Your name* Your email address*

When you have submitted this form please complete a statement using the link on college communications.

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Hillson Drive, Fareham, Hampshire, PO15 6PH

tel: 01329 843127

email: enquiries@henrycort.org

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