Complete this form to report an accident, incident or near miss.
Part one
The employee involved in the accident, incident or near miss should complete this section. If they cannot, their manager or supervisor can complete it on their behalf.
Part two
The manager or supervisor of the individual or establishment should complete this section.
If the accident involved a member of the public or a non-employee, such as a contractor, service user or visitor, the site manager should complete the form.
Data protection
We will use the information in this form to carry out a preliminary investigation into the cause and nature of the accident, incident or near miss.
We may also use it to complete statutory returns to the Health and Safety Executive (HSE) under the Reporting of Injuries, Diseases and Dangerous Occurrence Regulations (RIDDOR), where applicable.
