Incident report form - for accidents, near misses and disease
Spennymoor site
Date of report
-
Day
-
Month
Year
Date
Name of person affected by accident, near miss or disease
*
First Name
Last Name
Is the person an
*
Employee
Contractor / Subcontractor
Visitor
Member of the public
Other
Line manager or company name
*
What type of report is being submitted?
*
Near miss
Minor injury
Over 7 day injury
Specified injury
Fatality
Occupational disease
Environmental incident
Date of occurance
-
Day
-
Month
Year
Date
Time of occurance
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
:
Hour
00
10
20
30
40
50
Minutes
Was incident reported within
*
1 hour
Same day
24 hours
48 hours
1 week
Other
Location of incident (be as specific as possible - add image of location at end of report)
*
Please give description of injury and or damage
*
Tools, equipment etc. involved in the incident
*
Statement of person involved in the incident
*
Witness/Witnesses (will be contacted where additional information is required)
*
The details contained in this form are as accurate as possible (to be signed by person involved with incident).
*
Person who completed form
*
First Name
Last Name
Submit
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