RIDDOR Incident Assessment and Record Form

Enter the internal reference used for this incident record.

Enter the date on which the incident occurred.

Record the time or an approximate time, including the time zone if relevant.

State the school site, building, room, outdoor area or other relevant location.

Give a factual account of the sequence of events, the work or activity being undertaken, and the immediate circumstances.

Record first aid, medical attention, safeguarding or site-control actions taken, as applicable.

Enter the name of the person affected by the incident.

Select the status that best describes the affected person at the time of the incident.

If the affected person was not directly employed by the school, describe the agency, employer, contractor or other arrangement and the relevant premises-control facts.

Select the current assessment and explain the basis for it.

Explain how the work, workplace, work activity or premises contributed to the incident, or why the incident is not considered work-related.

Select all categories that describe the incident or its assessed potential.

Describe the injury, diagnosis, symptoms, treatment, potential harm or other outcome. Do not include information that is not relevant to this assessment.

Complete this field only where a specified industrial disease has been diagnosed.

Complete this field for a worker affected by an accident. Enter the number of days of incapacity known at the time of assessment; if the period is ongoing, record the current number and explain below.

Select the option that describes the current information.

Select all categories that the assessment considers applicable, or select none if no category is currently considered applicable.

Record the facts supporting or not supporting each selected category and identify any information still required.

Assign responsibility based on the employment relationship, the particular facts and who is in control of the relevant premises.

Enter the name and role of the person responsible for coordinating the assessment or report.

Record the current decision. If the assessment is incomplete or responsibility is disputed, explain the next action and review date.

Record the evidence, threshold assessment, responsibility analysis and any uncertainty supporting the decision.

Complete only if a report or notification has been submitted.

Enter the reference issued for the submitted notification, if one is available.

Enter the location or reference for the retained incident record and supporting assessment information.

Complete when information is outstanding, incapacity is ongoing or the reporting decision may need to be revisited.

Record outstanding evidence, communications with the agency or employer, internal escalation, and actions needed to complete or review the assessment.

Select this only after reviewing the completed form and identifying any outstanding actions.

• Tick when complete