Accident / Incident Report Form

Please complete this form as soon as possible following any accident, incident, near miss, dangerous occurrence or unsafe event connected with the project or works.

This information assists with investigation, risk management, statutory reporting requirements and ongoing health & safety coordination.

If a question does not apply, please enter N/A. If you experience any issues completing this form, please contact pd@evolutionsafetysolutions.co.uk.

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1. Person Reporting the Incident

Your Name

Your Email Address

Company / Organisation

Your Role

—Please choose an option—Principal ContractorSite ManagerSupervisorOperativeSubcontractorPrincipal DesignerDesignerClientVisitorOther

If Other, please provide details

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2. Project Information

Project Title

Project Address

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3. Incident Details

Date of Incident

Time of Incident

Exact Location of Incident

Type of Incident

—Please choose an option—AccidentNear MissDangerous OccurrenceProperty DamageEnvironmental IncidentFire IncidentInjuryUnsafe ConditionUnsafe ActOther

If Other, please provide details

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4. Person(s) Involved

Name(s) of Person(s) Involved

Company / Employer of Person(s) Involved

Injury Sustained?

—Please choose an option—YesNo

If Yes, please provide injury details

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5. Incident Description

Description of Incident

Please provide a clear factual description of what happened.

Immediate Actions Taken

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6. Potential Causes / Contributing Factors

Please identify any known or suspected contributing factors.

Unsafe AccessPoor HousekeepingLack of SupervisionFailure to Follow RAMSEquipment FailureHuman ErrorInadequate TrainingPoor CommunicationWeather ConditionsTemporary Works IssuePlant / Vehicle MovementService StrikeWork at HeightManual HandlingEnvironmental ConditionsOtherUnknown

If Other, please provide details

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7. Emergency Response

Were Emergency Services Contacted?

—Please choose an option—YesNo

If Yes, please provide details

Was First Aid Provided?

—Please choose an option—YesNo

If Yes, please provide details

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8. RIDDOR & Further Investigation

Is the incident potentially RIDDOR reportable?

—Please choose an option—YesNoUnknown

Further Investigation Required?

—Please choose an option—YesNo

Investigation / Follow-Up Details

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9. Corrective Actions

Corrective Actions Required

Please include responsible persons and target dates where applicable.

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10. Witness Information

Witness Details

Please include names and contact details if applicable.

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11. Photographs & Supporting Documents

Please upload any photographs, witness statements, reports or supporting documentation relevant to the incident.

If no documents are available, please upload a simple note stating “No documents available”.

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12. Additional Comments

Additional Comments

Enter N/A if you have no further comments.

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13. Declaration

Please confirm that the information provided is accurate to the best of your knowledge.

[acceptance* declaration] I confirm that the information provided within this form is accurate and complete to the best of my knowledge. [/acceptance]