Business Unit
Please Select
BusinessWatch
Securiplex
RMS
Accident / Incident / Near Miss Record
Person who had the Accident / Incident / Near Miss
Date and Time of Accident / Incident / Near Miss Reporting
*
-
Day
-
Month
Year
Date
Hour Minutes
What Type of Occurrence Are You Reporting?
*
Please Select
Accident
Incident
Near Miss
Information Only
Did the Accident / Incident / Near Miss Occur on a Water Site?
Yes
No
What utilities contract did this happen on?
*
Please Select
Yorkshire Water
Severn Trent
SST/ CAM Water
Southern Water
Name
*
Occupation
*
Contact Email
*
Contact Number
*
Back
Next
Person Filling in this Report
Same as Previous
Name
*
Occupation
*
Contact Email
*
Contact Number
*
Back
Next
Details of Accident / Incident
Date and Time of Accident / Incident / Near Miss
-
Day
-
Month
Year
Date
Hour Minutes
Location of Accident / Incident / Near Miss
How did the Accident / Incident / Near Miss Happen?
If Any Injuries Were Suffered Please Provide Details, Including Location and Severity of Injury
Was First Aid Administered?
Yes
No
What First Aid Was Administered and by Whom?
Name and Contact Details of Any Witnesses
Upload Any Photos or Evidence
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Back
Next
Details of Information Only
Date and Time information collated
-
Day
-
Month
Year
Date
Hour Minutes
Location of highlighted issue
How did the highlighted issue happen?
If Any Injuries Were Suffered Please Provide Details, Including Location and Severity of Injury
Was First Aid Administered?
Yes
No
What First Aid Was Administered and by Whom?
Name and Contact Details of Any Witnesses
Upload Any Photos or Evidence
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Back
Next
Details of Near Miss
Date and Time of Near Miss
-
Day
-
Month
Year
Date
Hour Minutes
Location of Near Miss
Describe the Near Miss or Unsafe Act Observed
What Remedial Action has Been Taken?
Was first aid administered?
Yes
No
What was the Category of Near Miss?
Housekeeping Standards Inadequate
Housekeeping Standards Not Known or Understood
Housekeeping Standards Not Being Followed
Behaviour - Horseplay
Behaviour - Inattention to Surroundings
Procedural - Procedures Inadequate
Procedural - Procedures Not Known or Understood
Procedural - Procedures Not Being Followed
Training - Not Trained for the Activity
Training - Other Training Not Completed
Contact with / exposure to harmful or biological substance
Contact with electricity or electrical discharge
Contact with hot surface / substance
Contact with moving machinery, object or substance
Contact with sharp object
COVID-19
Drowning or asphyxiation
Employee personal safety (violence / physical or verbal assault
Fall from height
Fire or explosion
Health condition
Injured by animal / insect
Lifting and handling injury
Lifting equipment failure
Lone worker false alarm
Manual handing
Process safety – Activation of safety instrumented system
Process safety – Loss of primary containment
Process safety – Safety critical equipment failed / defeated
Slip, trip, fall polymer spillage
Slip, trip, fall on same level
Struck by moving vehicle
Struck by moving, flying or falling object
Struck, caught against, trapped
Trapped by something overturning / collapsing
Uncontrolled release of hazardous substance
Vehicle collision / road traffic collision
Working time regulations
Upload Any Photos or Evidence
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Back
Next
*
I confirm the above details are correct
Signature
*
Name
*
First Name
Last Name
Date
*
-
Day
-
Month
Year
Date
Hour Minutes
Submit
Should be Empty: