DANGEROUS OCCURRENCE FORM

(Where there has been no injury caused)

Report reference number:
Date and time of incident:
Date and time of report:

Address/Location of incident:

Work order/client reference:

Nature of job and RAMS reference number:

Employees involved in incident:

(Names/addresses/payroll reference)

Second/Third party staff involved:

Second/Third party witnesses:

Description of incident and circumstances:

Nature of Work directly involved during incident:

Foreseeable Accident Potential:

Did the incident represent a breach of statutory regulation? If so, which one(s)?

What steps were taken prior to the incident to have prevented its occurrence?

What steps have been taken, or proposed, to prevent similar incidents occurring in future
work?

Signature of person completing report:_____________________Date:______

Print name and job title:___________________________________________

Acknowledged by (Signature) :_________________________Date:______

Managing Director/partner

Print name_____________________________________________________
(Copies of the completed Incident Report are to be sent to the Safety Officer and retained fro at least five years, following the incident)

Dangerous Occurrence Form Page 1 of 1 Document Number HSR-RIDDOR_2008/B