Health, Safety & Environmental Incident Report Form

• Project No (If Applicable)

• Project / Incident Location
  Address

• Date of Incident

  Date

• Incident Report Number (To be completed by Safety Officer)

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• What is the type of Incident that you are Reporting? (Tick as appropriate)

  Select Fatality Lost Time Injury Dangerous Occurrence Disease First Aid Injury Environmental Incident Fire Collapse

  • Fatality
  • Lost Time Injury
  • Dangerous Occurrence
  • Disease
  • First Aid Injury
  • Environmental Incident
  • Fire
  • Collapse

• Surname

• Forename(s)

• Home Address

• DOB

• Telephone Number

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• How is the person affected/injured connected to the location?

  Select

• If Other, please state who

• If subcontractor, state to whom:

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• Trade / Occupation:

• Company name and address (if non TKL):

• Company Telephone no:

• Company Fax Number

Details of any injuries (if applicable)

• Give Details

• Injury Type

  Select Fracture Laceration/Puncture Bruise Strain/Sprain Burn Contamination Crush Avulsion/Degloving

  • Fracture
  • Laceration/Puncture
  • Bruise
  • Strain/Sprain
  • Burn
  • Contamination
  • Crush
  • Avulsion/Degloving

Details of Incident

• Exact location of Incident
  Address

• Work Process being undertaken at the time of Incident – (Include plant & machinery involved)

• Brief description of incident. In the case of an injury, state what the injured person was doing at the time.

• If injury was caused by fall, please state how far injured person fell (in metres)

Actions Taken/Recommendations:

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• Name of person making entry: (state occupation and address if not injured person)

• Signature:

  Sign

• Date:

  Date

• Incident to be notified under RIDDOR

  Yes

  No

• Signature:

  Sign

Overall Incident Severity

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  Select Catastrophic Major Moderate Minor Insignificant Near Miss

  • Catastrophic
  • Major
  • Moderate
  • Minor
  • Insignificant
  • Near Miss