The SFE - Doc 41 Colchester Road Fireman

SUFFOLK FIRE SERVICE

ACCIDENT REPORT FORM

Part 1

About the Injured Person

Complete all Sections in this Part

Name A Wigglesworth

Date 1st May 1998 Time 10.00 hrs

Date of Birth 08.12.55 Sex Male

Status

Are you an Employee of Suffolk Fire Service Yes

Brigade No 854 Job Title SubO

Normal Period Work 0900 – 1700 hrs

Part 2a Accident Details

Location Drill Yard Lowestoft

Describe Incident

Whilst setting up a decontamination exercise alone I raise 2 drill dummies from the ground onto the top of the water carrier and strained my back.

Part 2b

Further Details Attached Yes

Did Accident Involve a Fall No

Was PPE Worn Yes

Part 3 Witnesses

Nil

Part 4 Details of Injury

Nature of Injury Lower back is uncomfortable and stiff

Did Injured Book Sick No

Accident Book Completed Yes

Part 4a

Is Injured Able To Continue Normal Work Yes

Part 5 Action Taken by Person Responsible for Premises

None

Signed A Wigglesworth

Part 6 Incident Reference

Number 762


Part 7 For BHQ Use Only

All Action Completed Signed ADO Paul Seager

Signature of brigade Safety Coordinater Paul Seager 11/5/98 *

* See Doc 42