HFORM03: Incident Report Form¶

Form Reference: HFORM03 Version: 1.0 Classification: CRGI Information Form Owner: Sean Ashton, Operations Manager Purpose: Comprehensive incident, accident, near-miss and other event reporting and investigation form per HPROC15. Enables root cause analysis and corrective action implementation.

Document Control¶

Version	Date	Author	Change Summary
1.0	10/03/2026	Sean Ashton	Initial issue

1. Reporter Details¶

Field	Details
Reporter Name	_________________
Role/Position	_________________
Date of Report	_________________
Contact Number	_________________
Email	_________________

2. Incident Details¶

Field	Details
Incident Date	_________________
Incident Time	_________________
Location	_________________

Incident Type (select one)¶

☐ Injury (loss time or medical treatment)
☐ Near Miss (potential for injury, no harm occurred)
☐ Property Damage (equipment, building, vehicle)
☐ Environmental Release (spill, emission, discharge)
☐ Security Breach (unauthorized access, data, theft)
☐ Other: _________________

Incident Description¶

What happened? (Describe sequence of events)

What was the person doing at the time?

Environmental conditions (weather, lighting, noise, etc.):

3. Persons Involved & Injured¶

Primary Involved/Injured Person¶

Field	Details
Name	_________________
Role/Position	_________________
Length of service	_________________
Status	☐ Employee ☐ Contractor ☐ Visitor ☐ Other

Injury Details (if applicable)¶

Field	Details
Type of Injury	_________________
Body Part Affected	_________________
Severity	☐ Minor ☐ Moderate ☐ Serious ☐ Fatal
First Aid Given	☐ Yes ☐ No (By: _________________)
Medical Attention Required	☐ Yes ☐ No
Medical Facility	_________________
Hospital/Clinic Admission	☐ Yes ☐ No
Days Away from Work	____ days
Estimated Return to Work	_________________

Other Persons Involved¶

Name	Role	Injury	Body Part	Medical Attention
_________________	_________________	_________________	_________________	☐ Yes ☐ No
_________________	_________________	_________________	_________________	☐ Yes ☐ No

4. Witness Information¶

Name	Role	Contact	Account (brief)
_________________	_________________	_________________	_________________
_________________	_________________	_________________	_________________

Detailed witness statement:

5. Investigation¶

Root Cause Analysis¶

Method used:

☐ 5 Whys
☐ Fishbone Diagram
☐ Event Tree
☐ Other: _________________

5 Whys Analysis:

Why 1: _________________________________________________________________

Why 2: _________________________________________________________________

Why 3: _________________________________________________________________

Why 4: _________________________________________________________________

Why 5: _________________________________________________________________

Root Cause Identified:

Contributing Factors (select all that apply)¶

☐ Human (training, competence, error, violation, fatigue, attitude)
☐ Equipment (failure, design, maintenance, defect)
☐ Environment (temperature, humidity, lighting, noise, space, congestion)
☐ Process (procedure inadequate, unclear, not followed, conflicting)
☐ Management (planning, communication, supervision, resources, culture)

Detailed explanation of contributing factors:

6. RIDDOR Assessment¶

Is this reportable under RIDDOR 2013?

☐ Reportable to HSE
☐ Not Reportable
☐ Unsure

RIDDOR Reportability Criteria:

Work-related fatality
Work-related serious injury (fracture, amputation, loss of consciousness, etc.)
Work-related injury preventing work for > 7 consecutive days
Work-related occupational disease diagnosis
Work-related dangerous occurrence

Justification:

If reportable, HSE reference number: _________________

Date reported to HSE: _________________

7. Environmental Impact Assessment¶

Was there environmental impact?

☐ None
☐ Spill/leak (quantity: _________________, substance: _________________)
☐ Emission to air (type: _________________)
☐ Waste generation (type/quantity: _________________)
☐ Other: _________________

Immediate containment/cleanup actions:

Environmental register updated (HREG05): ☐ Yes
☐ No

8. Corrective Actions¶

Action	Responsible Person	Target Completion Date	Status
_________________	_________________	_________________	_________________
_________________	_________________	_________________	_________________
_________________	_________________	_________________	_________________

9. Notifications Required¶

Recipient	Notification Type	Date Notified	Method
HSE (if RIDDOR)	Formal Report	_________________	_________________
Insurance company	Claim notice	_________________	_________________
Client (if applicable)	Incident notice	_________________	_________________
Staff (briefing/alert)	Safety briefing	_________________	_________________

10. Sign-Off¶

Role	Name	Signature	Date
Reporter	_________________	_________________	_________________
Investigator	_________________	_________________	_________________
Operations Manager	Sean Ashton	_________________	_________________
CEO (if serious/RIDDOR)	Dragos Ciordas	_________________	_________________

Investigation completed: ☐ Yes
☐ No
(Date: _________________)

Incident closed: ☐ Yes
☐ No
(Date: _________________)

HPROC15: Incident Reporting & Investigation Procedure
HPROC16: Root Cause Analysis Procedure
HREG09: Incident Register
HPOL04: Health & Safety Policy
HPOL18: Occupational Health Policy
HFORM05: Corrective Action Form

Retention: 5 years from incident date (7 years if RIDDOR reportable) Storage: CRGI Secure Document Management System Access: Reporter, Investigator, Operations Manager, CEO, Occupational Health Classification: CRGI Information — Confidential

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