Incident Report Form
Date of incident and person reporting
Date of Incident
Time of Incident
Date of Report
Name
Title
Please Choose
Mr
Mrs
Ms
Miss
Cl
TI
UA
PCI
AI
PPO (SCC)
P/Sgt (SCC)
A/PO (SCC)
A/Sgt (SCC)
PO (SCC)
Sgt (SCC)
ACPO (SCC)
A/Col Sgt (SCC)
CPO (SCC)
Col Sgt (SCCT)
WO1 (SCC) RNR
WO2 (SCC) RNR
WO1 (SCC) RMR
WO2 (SCC) RMR
Mid (SCC)
2nd Lt (SCC) RMR
S/Lt (SCC) RNR
Lt (SCC) RMR
A/Lt (SCC) RMR
A/SLt (SCC) RNR
Lt (SCC) RNR
A/Lt (SCC) RNR
Capt (SCC) RMR
Lt Cdr (SCC) RNR
Maj (SCC) RMR
Cdr (SCC) RNR
Lt Col (SCC) RMR
Chaplain RNR
Contact Tel
Contact Email
Job / Position
About the incident
Incident Type
Near Hit
NO Injury
Injury
Category
Minor
Serious
Major
Catastrophic
If Major or Catastrophic, the incident must be report to the HQ Duty Officer on 020 7654 7070 at the earliest opportunity.
Location
Area
Please Choose
Eastern
London
Northern
North West
Southern
South West
Location Details
Physical Location
Inside
Please Choose
Galley/Kitchen
Classroom
Office
Mess
Accommodation
Boat Shed
Store
Other
Outside
Please Choose
Parade Ground
Car Park
Road
Near Water
On Water
Other
Transport
Please Choose
Hired
Unit Owned
Public
Private
MoD
Other
Other description
Describe what happened
Work / Activity
Please Choose
1. Adventure training, hiking etc
2. At height, ropes, climbing etc
3. Building, equipment, content maintenance and repair
4. Ceremonial, representation, presentation and interest visits
5. Fundraising
6. Inspection, audit, review, visits
7. Maritime (not swimming)
8. Office and administrative
9. Other (not included elsewhere)
10. Sports (not maritime activity) but inc swimming
11. Travelling - walking, cycling, road, rail, sea and air.
12. Unit, SCTC, event, use, teaching, lessons and unit routine
13. Weapons and ammunition
14. Welfare related to use of welfare facilities, resting, sleeping, consumption or preparation of food
15. Stores Activities
The description is very important. You must be accurate and factual. Due to data protection requirements please do not use names or any sensitive information. Please use role/s or, if known, PNumber. For injured party use the term IP.
Guidance
Description
Immediate causes
Place / Premises
Please Choose
1. No place or premises involved
2. Failure/ collapse
3. Unsuited
4. Housekeeping/Obstacles
Procedure
Please Choose
1. No procedural cause
2. Inadequate procedure
3. Procedure not followed
4. Procedure not enforced
Person
Please Choose
1. No personal cause
2. Person not trained
3. Person not supervised
4. Person not competent
5. Person not capable
6. Ignored / Disregarded rule
7. Lack of attention / distracted
Activity
Please Choose
1. No activity cause
2. Uncontrolled activity
3. Insufficient controls
4. Inadequate controls
5. Recognised Potential outcome
Equipment / Substances
Please Choose
1. No equipment or substance involved
2. Failure of equipment
3. Release of substance
4. Unexpected equipment movement
5. Incorrect equipment or substance use
6. Incorrect use of equipment or substance
Criminal act
Please Choose
1. No Criminal Cause
2. Theft
3. Break-in
4. Arson
5. Vandalism
Actions taken
Safe System of Training followed?
Yes
No
Not applicable
Activity covered by a Risk Assessment?
Yes
No
Not applicable
Lessons Learnt
Statements taken?
Yes
No
Photos taken?
Yes
No
Police informed?
Yes
No
Crime ref number
Police station address / details
About the person injured or suffering ill health
Category
Cadet
Volunteer
Employee
Contractor
Visitor
Public
Gender
Male
Female
PNumber
(if applicable)
Age
About the injury or illness
Injury type
Cut
Break
Burn
Bruising, swelling, tenderness
Dislocation
Stab/penetrating injury
Sprain/strain
Amputation
Other
Not Applicable
Description of injury type
Part of body
Abdomen
Fingers/thumbs
Lower leg
Toes
Ankle/foot
Groin
Lungs
Upper arm, inc elbow
Back/spine
Hand
Neck
Upper leg, inc knee
Chest
Head
Shoulder
Whole body
Eyes
Lower arm
Throat
Wrist
Not Applicable
Treatment
None
Advised to visit GP
Emergency services called
First aid administered
Taken to hospital
Hospitalisation
Was this an existing medical condition?
Yes
No
Details of existing medical condition
Insurance
Is an insurance claim likely?
Yes
No
If the answer is yes, please fill out as much of the below as possible.
1. Loss or damage to property, or injury to third party
Ownership
MSSC
Unit
MoD
Third Party
Person responsible for the property at the time of damage/loss
Motor vehicle involved?
Yes
No
Cost/value of claim £
Full description of property
2. Third party details
Details of third party (if applicable)
Details of any communication received from third party
3. Loss or damage to boats
Description of craft
Name and/or number
Class or type
Engine type and capacity
Fuel
Ownership
MSSC
Unit
MoD
Third Party
Agreed value of craft £
Location of accident
Moorings
Underway
Please state exact location
Was the craft used for Sea Cadet training at the time of the accident?
Yes
No
If not, for what purpose was the craft used?