Civil Engineering Reference
In-Depth Information
Appendix 12.1
F2508 RIDDOR report form
Health and Safety at Work etc Act 1974
The Reporting of Injuries, Diseases and Dangerous Occurrences Regulations 1995
Incident No.
Report of an injury or dangerous occurrence
Injury
Dangerous Occurrence
Part A
If you do not know the postcode, what is the name of the local
authority?
About you
1
What is your full name?
4 In which department, or where on the premises, did the incident
happen?
2
What is your job title?
3
What is your telephone number?
Part C
About the injured person
If you are reporting a dangerous occurrence, go to Part F. If more than
one person was injured in the same incident, please attach the details
asked for in Part C and Part D for each injured person.
About your organisation
4
What is the name of your organisation?
1
What is their full name?
5
What is its address and postcode?
2
What is their home address and postcode?
6
What type of work does the organisation do?
3
What is their home phone number?
Part B
About the incident
1
4
How old are they?
On what date did the incident happen?
/
/
5 Are they?
2
At what time did the incident happen?
male?
(Please use the 24-hour clock eg 0600)
female?
6
What is their job title?
3
Did the incident happen at the above address?
Yes
Go to question 4
7
Was the injured person (tick only one box)
No
Where did the incident happen?
one of your employees?
elsewhere in your organisation -
give the name, address and postcode
on a training scheme? Give details:
at someone else's premises -
give the name, address and postcode
in a public place - give details of
on work experience?
where it happened
employed by someone else? Give details
of the employer:
