1. HERTFORDSHIRE COUNTY COUNCIL INJURY OR DANGEROUS OCCURRENCE REPORT (IDOR) FORM DEPARTMENT ____________________ PERSON COMPLETING REPORT NAME & ADDRESS OF ESTABLISHMENT, NAME ______________________________________________ OFFICE, DEPOT ETC. _________________________________________________ POSITION ___________________________________ ________________________________________ TEL NO. & EXT. ______________________________ DEPT LOCATION DATE CODE CODE SIGNATURE. ___________________ TYPE OF REPORT (please tick as appropriate) PERSON IN CHARGE OF ACTIVITY AT TIME OF INCIDENT (if different from above) 1. PERSONAL INJURY 2. NOTIFIABLE DANGEROUS OCCURRENCE NAME ____________________________________ 3. OTHER - NEAR MISS Report 2 also requires F2508 to be completed for HSE POSITION _____________________________________ Refer to departments Safety Statements and notes of guidance for local procedures. DETAILS OF PERSON INJURED/INVOLVED (please tick as appropriate) (ONE PERSON PER FORM) SURNAME ______________________________ HCC EMPLOYEE STUDENT/PUPIL OTHER NAMES _________________________ CONTRACTOR RESIDENT AGE ___________ SEX M F VISITOR/MEMBER OTHER “CLIENT” OF PUBLIC JOB TITLE/RANK _______________________ VOLUNTARY ACTIVITY AT TIME WORKER HCC PAY NO OR FIRE OF INCIDENT & RESCUE UER NO. _________________________________________________ OCC. CODE ADDRESS OF NON-EMPLOYEE ___________________________________ ________________________________ ACTIVITY CODE __________________________ WAS ANYBODY ELSE INVOLVED? YES NO DETAILS OF INCIDENT EXACT LOCATION _____________________________ DATE TIME _______________________________________ OCCURRED _________ AM/PM ___________________________________________________________ REPORTED _________ AM/PM FACTUAL DESCRIPTION OF EVENTS & CIRCUMSTANCES (IF FALL OF PERSON OR MATERIALS GIVE HEIGHT OF FALL) (Attach additional sheets if necessary and sketchplan where appropriate) PROTECTIVE CLOTHING/EQUIPMENT USED PLANT/EQUIPMENT/VEHICLES INVOLVED MATERIALS/SUBSTANCES/CHEMICALS INVOLVED (NAME,TYPE,PARTS,REG.NUMBER,WHETHER IN MOTION)(TYPE,TRADE NAME,CHEMICAL DESCRIPTION) AGENT CODE OFFICIAL USE Appendix A

2. DETAILS OF INJURY AND TREATMENT Was injury sustained? YES NO If YES, give details of nature, site and extent ____________________________________________________________________ RISK CODE ____________________________________________________________________ BODY CODE TYPE OF TREATMENT: HOSPITAL DOCTOR FIRST AID REST NONE DETAILS OF TREATMENT _________________________________________________ INJURY CODE NAME & ADDRESS OF HOSPITAL/DOCTOR (If appropriate) WITNESS/ES ____________________________________________________NAME __________________________________ ____________________________________________________ADDRESS _______________________________ _________________________________________ If an employee, has the injury resulted in absence(ATTACH STATEMENT) from work?YES NO HSE STATUTORY REQUIREMENTS If yes, did he/she do any work on the day ofIs incident notifiable to HSE? (See Departmental the incident after it happened?YES NOSafety Arrangements) YES NO IF YES: What time did he/she stop work? _______________am/pm HSE notified by phone? YES NO Anticipated duration of absence _______________ daysHSE form F2508 sent? YES NO BY: NAME DATE IF THIS FORM HAS NOT BEEN COMPLETED BY THE MANAGER, MANAGER MUST SIGN HERE TO INDICATE THAT THEY ARE AWARE OF ACCIDENT/INCIDENT DETAILED OVERLEAF AND ABOVE. Manager’s Name:Signature:Date: INVESTIGATION - THIS SECTION MUST BE COMPLETED NB: All Accidents/Incidents need to be investigated to determine their cause and prevent recurrence. Please refer to Departmental Policy and Procedures and/or the County Policies and Procedures Guidance Handbook. Give details of any discrepancies found in the information given and any action taken to determine the cause or prevent recurrence. ( Additional sheets may be submitted with this form) Has any previous complaint/report relating to the incident, or its cause been made? YES NO If YES, please give details Investigating Officer: NAME SIGNATURE POSITION TEL NO. DATE Completion of this form does not constitute a claim against the County Council. NOTE: This form should be completed as soon as possible after the accident/incident and processed in accordance with your departmental arrangements and the original sent to the CSF HEALTH AND SAFETY TEAM, ROOM 159, COUNTY HALL, HERTFORD SG13 8DF OFFICIAL USE