LEGALANDMANAGEME

NT GA18 Accident/incident report

Instructions for use
1. To be completed and returned as soon as possible after any incident/accident (please print clearly).
2. To be used for all incidents (minor and reportable), dangerous occurrences, near misses,
environmental incidents, complaints, thefts and incidents involving material damage, including
cable strikes.
3. Keep site copy in a secure place (General Data Protection Regulation).

Company name This form consists of pages

Incident date Incident time (24-hour clock)
Incident type (tick boxes for all that apply and then complete further parts of this form as indicated)
Fatality* Parts A, B (i and ii) and F Minor incident/injury (no first 0
aid)
Dangerous occurrence*
Specified injury* Parts A, B (i and ii) and F Parts A ,B (ii) and F
(RIDDOR reportable)
=Over seven-day injury* Parts A, B (i and ii) and F Environmental incident Parts A, C and F =
Near miss/dangerous
Reportable disease* Parts A, B (i and ii) and F Parts A and F
occurrence (Not RIDDOR9
reportable)
Ill health Parts A, B (i and ii) and F Utility damage Parts A, D and F
Parts A, E and F
First aid (on site) Parts A, B (i and ii) and F Theft/vandalism/violence
(also B (i) for violence)
Medical treatment (off site) Parts A, B (i and ii) and F Complaint9999 Parts A and F

*HSE incident notification number Date reported

Part A – Description of incident

Where on site did the incident
occur?
Were photographs taken? Yes No (include copies with this form) Were samples taken? Yes No

Describe what happened and how. In the case of an injury, state what the injured person was doing at the time and side of
body where the injury occurred (left or right). (Where possible, take photographs of the general area but not of injured persons.)
In the case of an environmental incident, state the events that caused the incident (details of plant involved; photographs,
wherever practicable, must be taken). In the case of damage, indicate if it is to permanent works, temporary works, plant,
temporary buildings/contents or employees’ personal effects. (Photographs must be taken)

Please sketch the general area of the incident (include any relevant measurements)
(If more space is required, attach additional sheets and include references to them in this box)

Name Position Employer

Can it be established what company caused the incident? Yes No N/A

Give details (company’s name and individual’s name)

2024 Conforta sarl

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GA18Accident/incident reportcontinued

Part B – Health and safety

Part B(i) – Details of injured person
Date of Signature
Surname Forename(s)
birth (if possible)

Address

Contact
Postcode Position
telephone no.
Was any Date work Time Date work Time work
Yes No
time lost? finished work restarted restarted
finished

Name and telephone no. of hospital (where applicable)

Detail all PPE required by

Detail all PPE worn at time
the risk assessment for
of incident
the operation

Details of person’s employer (name, address and telephone)

If member of the public then write ‘public’

Location of injury (tick boxes for all that apply)

Head Chest Arm/shoulder Finger Foot Other (state below)

Face/neck Abdomen Wrist Leg/hip Respiratory system

Eye Back Hand Ankle Digestive system

Type of injury (tick boxes for all that apply)

Amputation Strain/sprain Foreign body Multiple Crush

Bruising/swelling Asphyxiation/gassing Fracture Shock/concussion Ingestion

Dislocation Loss of consciousness Burn/scald Puncture Internal

Electric shock Cut/laceration/abrasion Whiplash Ill health

Other (state)

Was the injured person advised to see their doctor or visit a hospital? Yes No

Is drug or alcohol testing required? Yes No Details of result Positive Negative

Part B(ii) – Details of incident

Basic cause of incident (tick one box only)
Fall from height Manual handling Repetitive motion/action

Fall on same level Contact with Collision

tool/equipment/machinery
Fall down stairs/steps Contact with flying particle Fire

Struck by moving object Contact with electricity Explosion

Struck by falling object Contact with/exposed to heat/acid Drowning

Struck/trapped by something Contact with/exposed to air/water Loss of containment/unintentional
collapsed/overturning pressure release
Contact with/exposed to hazardous
Trapped between objects Asphyxiation
substance
Step on/struck against stationary Exposure to noise/vibration Other (state)
object
Source of hazard (tick one box only)
Lifting equipment Scaffold Temporary works Flying particle

Vehicle/mobile equipment Excavation Materials Dust

Static equipment/machinery Stairs/steps Floor/ground condition Proximity to water

Moving parts of machinery Working surface Lack of oxygen Workstation layout

Power tool Structure Heat/hot work Hazardous substance

Hand tool Ladder Cold Other (state)

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GA18Accident/incident reportcontinued

Part C – Environmental incident

Type of incident (tick boxes for all that apply)
Air pollution Noise or vibration Plants or wildlife Fly tipping

Water contamination Ground contamination Waste disposal

Other (state)

Severity of incident (tick one box only)

Minor Significant Major

Has incident been reported to the Contact

Yes No
environment agency/NRW/SEPA/NIEA? details/reference

Part D – Utility damage

Description of service Owner of service

Cause of damage (please tick as appropriate)

Plant owner’s
Mechanical plant Hand-operated plant Hand tools name/plant hire
company’s name
Other (state)

If the plant was on hire, state to whom

Date and time

Who undertook the repair of the service?
repair undertaken

Was the service clearly shown on permit to dig? Yes No If ‘No’ state why

State company Will they be

responsible for invoiced direct
Yes No If ‘No’ state why
the damage in by utility
your opinion company?

Details of communications with company responsible for damage

Reference of correspondence
Date on correspondence
(such as unique letter reference)

Part E – Theft/vandalism/violence
Item stolen Serial no. Value Owner

Crime Date Name of person

number/police and time who reported the
log reference reported incident
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GA18Accident/incident reportcontinued

Part F – Root cause and prevention (tick boxes for all that apply)
Work environment

Defective workplace Lighting Design/layout Noise/distraction

Housekeeping Weather Lack of room Access/egress

Human factors
Failure to adhere to risk
Failure to follow rules Lack of experience Fatigue
assessment
Working without
Instructions Unsafe attitude Horseplay
authorisation
misunderstood
Error of judgement Undue haste Lapse of concentration

PPE

Design Poorly Not used

maintained/defective
Wrong type used Not provided/unavailable

Management

Non-communication of Supervision Training System failure

risk
Plant/equipment

Construction/design Safety device Mechanical failure

Installation Operation/use Poor/lack of maintenance

Other

Third party Under investigation Other (state)

Details of actions taken immediately following the incident to recover the situation

Action taken (or suggested) to prevent reoccurrence and to communicate lessons learnt from the incident

Person completing the form

Name Position Signature Date

Person with overall workplace responsibility

Name Position Signature Date