Title Page
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Name of the person reporting the accident, incident or near miss (AINM) (if not the person who had the AINM)
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Occupation/ Position of the person reporting the AINM
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Name of the person who had the AINM
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Occupation/Position of the person who has the AINM
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Was it an Accident (result in injury), Incident (potential to cause injury) or Near Miss (nearly cause injury)?
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Date of AINM
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Time of AINM
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Where did the AINM happen?
Details of the accident, incident or near miss
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Who was present at the time of the AINM?
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How did the AINM happen? Give details of the events and the cause?
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Was anyone else involved in the AINM?
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Occupations of the other persons involved in the AINM
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Was the person involved in the AINM injured? If so what was the injury? Give a description of the injury and type (e.g.minor, number of days absent from work, major etc.
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Were any of D&S IFCA assets damaged? If so give details
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Do you give your consent to D&S IFCA to disclose your personal information and details of the accident which appear on this form to relevant organisations (e.g., HSE, Peninsula) for then to carry out health and safety functions given to them by law. This includes the reporting requirements under RIDDOR 2013?
