IMS Hazard/Near-Miss Report V2

This form is to be used for Hazard & Near-Miss reports ONLY. For incidents, please contact the Incident Desk on the usual number. The template is ideally used in real time at the incident site via Smart phone - iPad etc. If the report is due to faulty equipment/tooling - Careline MUST be informed.

• Hazard/Near-Miss? Hazard = Something that can hurt or damage. Near Miss = Something happened, but no-one/nothing was hurt or damaged.

  Hazard

  Near Miss

• Employee Type (Who is involved?)

  Cadent

  Contractor

• Add contracting company if a contractor.

• Date and time of incident (When did the incident happen?)

  Date

• Employee involved (if reporting on behalf of)

• Reported by (Your name)

• Name of manager notified (if you are staff and no escalation is required, put in your own name)

• Date and time manager notified?

  Date

• Responsible Manager (Manager for area/process)

• Contact telephone number (your number)

• Line Manager (your line manager)

• Geographical/Process Area

  Select NW Ops. WM Ops. EA Ops. EM Ops. London E Ops. London W Ops. Business Assurance Central Ops Construction Transformation Smart Metering Safety & Network Strategy Other

  • NW Ops.
  • WM Ops.
  • EA Ops.
  • EM Ops.
  • London E Ops.
  • London W Ops.
  • Business Assurance
  • Central Ops
  • Construction
  • Transformation
  • Smart Metering
  • Safety & Network Strategy
  • Other

• Process/Structure (Select most relevant)

  Select Repair Emergency O&M Replacement Streetworks SHE Keyhole Office Staff Technical Other Safety Assurance Ops Management Management

  • Repair
  • Emergency
  • O&M
  • Replacement
  • Streetworks
  • SHE
  • Keyhole
  • Office Staff
  • Technical
  • Other
  • Safety Assurance
  • Ops Management
  • Management

• If you are manually inputting the address, please ensure you input FULL address details including postcode.

• Address of Hazard/Near-Miss (press button to right if you are on site and press on blue dot)
  Address

• Location Type (Field Location, Depot, AGI, Office, Kiosk, Construction Site, etc.)

• Task/Activity

  Select Leak Investigation Excavation Work Site Investigation Driving or Mobile Equipment Live Gas Work General Maintenance Office Work Inspection Metering Work Lifting/Carrying/Reaching Loading/Unloading Electrical Work Installing wire/Equipment/Pipe Other

  • Leak Investigation
  • Excavation Work
  • Site Investigation
  • Driving or Mobile Equipment
  • Live Gas Work
  • General Maintenance
  • Office Work
  • Inspection
  • Metering Work
  • Lifting/Carrying/Reaching
  • Loading/Unloading
  • Electrical Work
  • Installing wire/Equipment/Pipe
  • Other

• What Happened? (This will form your report)

• Action (What action have you taken to resolve this?)

THE BELOW IS ONLY REQUIRED IF YOU HAVE 2 OR LESS ADDITIONAL HAZARDS. Additional Hazards below are only to be used on same site when all other information above is the same.

• Additional Hazard 1 (Include Action)

• Additional Hazard 2 (Include Action)

The template must now be sent (PDF ONLY) via email to box.SHE.Incident@cadentgas.com Export report and select 'send via email'.