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aaa Test Incident Page

Report an Incident

Report a near miss or incident via the form below. The report will be reviewed to determine whether a full accident investigation is required.

Name

First Last

Please leave blank if you wish to report an occurrence anonymously

Date of incident*

Time of incident*

Hours

Minutes

Department incident occurred within*

Location of Incident

Please provide detailed location eg What3Words, field number, etc

Incident Type*

Hazard

Near Miss

Accident resulting in damage

Accident resulting in damage and/or injury

Hazard

Hazard details*

Has hazard been removed?*

Yes

If hazard has not been removed please remove or report to area manager.

Near Miss

What happened?*

Who was involved?*

Which category does this fall under:

Slips, trips & falls

DSE

Machinery

Electrical

Workplace driving

Movement of vehicles and pedestrians

COSHH

Noise

Fire

Manual Handling

Did this nearly result in damage and/or injury?

Damage

Injury

None

What prevented this from being an accident?

Did the near miss involve any of the following

The failure of a pressurised system

The collapse, overturning or failure of lifting equipment

Contact with overhead powerlines

Fire or explosion

Explosives

Release of biological agent

The malfunction of breathing apparatus

The malfunction of radiation equipment

Diving operations

Collapse of scaffolding

Injury Information

Who was injured?*

Is the injured person an employee?*

Yes

Was the accident work related?*

Yes

Was the injured person taken from where the accident happened, to a hospital for treatment?*

Yes

Accident Information

What was happening before the incident?*

Background of what was happening before the incident occurred

How did the accident happen?*

What were the conditions at the time of the accident?

Dry ground

Wet ground

Cloudy

Icy/Snow on groung

Low sun

Raining/hailing/snowing

Foggy

Dark

Normal daylight

Which category does this fall under:

Slips, trips & falls

DSE

Machinery

Electrical

Workplace driving

Movement of vehicles and pedestrians

COSHH

Noise

Fire

Manual Handling

Damage Information

What was damaged?*

DFL Vehicle

DFL Property

DFL Staff Vehicle

DFL Staff Property

Third Party Vehicle

Third Party Property

Reg of damaged vehicle(s)*

What damage occured?*

Incident may be RIDDOR reportable

Submit

If you have any photos upload them here:

Drop files here or

Accepted file types: jpg, gif, png, pdf, Max. file size: 256 MB, Max. files: 10.

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