LS Events Company Report Form

LS Events Company Report Form
This form is used to report accidents, incidents, near misses, information security incidents, bullying and harassment, sexual harassment, as well as providing general feedback.

It is important that we report all instances so that measures can be put in place to mitigate the risk of repeat occurrences.

NB All reports should be completed within the first 24 hours following the accident/incident taking place.
Your Details
Name of person completing the report

First NameLast Name
Job Title
Email address of person completing the report
example@example.com
Phone number of person completing the report
Please enter a valid phone number.Format: 00000 000 000 .
About the occurrence
Definitions

Accident: An unexpected event which results in serious injury or illness of an employee and may also result in property damage.

Incident (incl. Security incidents): An instance of something happening, an unexpected event or occurrence that doesn’t result in serious injury or illness but may result in property damage.

Near Miss: An event not causing harm, but has the potential to cause injury or ill health.

InfoSec Incident: A single or a series of unwanted or unexpected information security events that have a significant probability of compromising business operations and threatening information security. DO NOT SELECT THIS FOR EVENT SECURITY INCIDENTS.

General: Feedback
I am reporting :
Project or Location
If other, please specify
W3W /// Location
e.g. wink.they.edit
Date of occurrence

DayMonthYear
Date
Time of occurrence

Hour Minutes
Medical
Was anyone involved injured?
Name of IP (injured person)

First NameLast Name
Email address of IP
example@example.com
Phone number of IP
Please enter a valid phone number.Format: 00000 000 000.
What was the cause of the injury?
Did the injury require medical attention?
Please detail the actions taken
Did the injury require hospitalisation?
Please provide any further details about the sustained illness or injury, including the name of the hospital (if known) if hospitalisation was required.
Were there any other casualties?
Please provide as much detail as you have including contact details.
Damage to property

Physical damage to permanent infrastructure, facilities or wildlife. These items include all Trees, Plants, Lamps, Drainage Systems, Benches, Gates, Roadways etc.
Was there any damage to property?
What damage was caused?
What was the cause of the damage?
Does this damage need to be reported to the client, supplier, landowner or Other?
Name of client/supplier/landowner/other to be informed
Hazardous Substances
Were any hazardous substances involved?
What substance was involved?
What actions were taken to contain the substance?
You will be able to provide full details of the occurrence in the next section of this form.
Information Security
Was this an actual or potential incident?
Did this incident involve personal data?
Have all affected parties been informed?
Details of the Event
Who was directly involved?
Including staff members, contractors, traders etc.
Please provide details of the event you are reporting. Give as much detail as possible (if not already captured above).
What happened? How did it happen? What were the factors leading up to the event and what happened immediately after? What was the root cause? Be Specific.
What actions have been taken in response?
What was the outcome? (if known)
Were there any follow up actions? Was this event properly reported? Were there any other actions was planned, implemented or recommended to prevent this from reoccurring?
Were there any witnesses to the event? Please provide names and contact details.
All employees should fill out their own account of what happened on a separate form.
Please attach any photos you may have to accompany your report.

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Reporting and RIDDOR
Is this accident/incident reportable under RIDDOR?
If you are not sure, please ask a Senior Manager
Has the Site Manager been informed?
Has the Employer been informed?
Has the HSE be notified?
HSE RIDDOR Ref. No.
Personal Data Breaches

You must report a notifiable breach to the ICO without undue delay, but not later than 72 hours after becoming aware of it. If you take longer than this, you must give reasons for the delay.
Is this incident reportable to the ICO?
Has the report already been submitted?
ICO Report Reference No.
General Feedback
Should be Empty:

LS Events Company Report Form

Your Details

About the occurrence

Medical

Damage to property

Hazardous Substances

Information Security

Details of the Event

Reporting and RIDDOR

Personal Data Breaches