Report near misses

Incidents, concerns or near misses

Please use this form to report all work-related accidents (including vehicle), injuries, infectious diseases, concerns and/or near miss incidents. This form should be completed as soon as possible after an accident or incident, or when a concern is realised. If the affected person cannot complete the form, it should ideally be completed on their behalf (with their permission) by someone else.

Once the form has been submitted it will be received by Gattaca’s Health & Safety department - someone may need to be in contact for further information.

What is your full name?

What company are you working at? *

What sector do you work within? *

Who is your recruitment consultant?

What brand have you been engaged via?

What is your email address?

Type of incident *

When did the incident happen? *

Day

Month

Year

What time did the incident occur? (approximately) *

Hour

:

Minute

Has this incident been reported internally at the company that you are working for, where the incident took place? *

Yes

No

What is the name and email address of who this has been reported to? *

Please specify why this hasn’t been reported internally at the company that you are working for, where the incident took place. *

Where did the incident happen? *

What happened? *

Were there any witnesses? *

Yes

No

Please provide names and contact details of any witnesses. (Please note that witnesses will need to provide their permission for you to complete this form with their details.) *

Was there an injury as a result of the incident? *

Please detail where, and what type of injury was sustained. *

If the injury resulted in time off work when you would have otherwise been working still, please detail the dates from and to. *

Please detail any treatment provided at the time or soon after. *

Did the incident involve a vehicle? *

Owned, company car, other (please specify) *

By submitting your information, you are agreeing to our privacy statement. To find out more about how we use and manage data, please click here.