Beruflich Dokumente
Kultur Dokumente
a full version of
the chapter
the chapter
the chapter
the chapter
the chapter
Dan Tyndall
August 2015
Reference Number:
YYYY/nn
Part 1 : Overview
Reported by
PASTORAL
CONCERN
ILL
HEALTH
INCIDENT
ACCIDENT
Brief details (What, where, when, who and emergency measures taken)
Forwarded to
Date
Time
Reference Number:
YYYY/nn
Reference Number
Each adverse event is to be assigned a sequential Reference Number (YYYY/nn). This reference
number is to be added to the footer of the electronic version of this form and written onto every
page of any version printed prior to a number being assigned. Parish Administrator and Health &
Safety Officer will be able to supply the correct next reference number.
What Ref No. has been assigned
Who assigned it
Y/N
Who added it
Y/N
Who wrote it
Type of event
Pastoral Concern
Fatal or major
Ill health
Serious
Incident: Near-miss
Minor
Little or none
Accident
CHURCH
OFFICE
Reference No:
Yes No
Date/time reported:
Minimal
Level
Low
Level
For investigation by
Reference Number:
YYYY/nn
Medium
Level
High
Level
Who was injured/suffered ill health or was otherwise involved with the adverse event?
How did the adverse event happen? (Note any equipment involved.)
Were there adequate safe working procedures and were they followed?
If there was an injury, how did it occur and what caused it?
Reference Number:
YYYY/nn
Was the risk known? If so, why wasnt it controlled? If not, why not?
10 Did the organisation and arrangement of the work influence the adverse event?
14 Did the nature or shape of the materials influence the adverse event?
15 Did difficulties using the plant and equipment influence the adverse event?
Reference Number:
YYYY/nn
Reference Number:
YYYY/nn
22 Which risk control measures should be implemented in the long and short term?
Control measure
Completion date
Person responsible
23 Which risk assessments and safe working procedures need to be reviewed and updated?
Risk Assessment or Safe Working Procedure
Completion date
Person responsible
24 Have the details of the adverse event and the investigation findings been recorded and
analysed? Are there any trends or common causes which suggest the need for further
investigation? What did the adverse event cost?
Reference Number:
YYYY/nn
Signature
Position
Reference Number:
YYYY/nn