Report near misses

Report incident/near misses form

Please use this form to report all work-related injuries, diseases, ill health, vehicle accidents or damage, and near miss incidents. This form should be completed as soon as possible after the incident. If the affected person cannot complete the form, it should be completed on their behalf by someone else within the same company.

Once the form has been submitted it will be received by the Gattaca Health & Safety officer who may be in contact for further information.

What is your name, job title & company? *

What is your email address? *

What is your usual place of work? *

Type of incident *

When did the incident happen? *

Day

Month

Year

What time did the incident occur? *

Hour

:

Minute

Where did the incident happen? *

What happened? *

What category best describes the incident? *

Please provide names and contact details of any witnesses *

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

What type of Injury was sustained? *

Give details including which part of body was affected and/or where damage was sustained *

Please enter type of treatment provided *

Did the injury result in time of work? *

Did the incident involve a vehicle? *

Registration and model of vehicle driven *

Owned, company car, other (please specify) *

Details of damage to vehicle *

Details of damage to 3rd party and/or injury to other individuals *

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