FORM G

ENTITY EHS INCIDENT REPORTING

Part A – Incident Notification

To be submitted to the Sector Regulatory Authority within 24 hours for all Reportable Incidents

1. General Information

Name of Entity:      

Registration
Classification Code:            
Number:

Address of Entity:      

Authorized Contact Person:       Email Address:      

Telephone Number:       Mobile Number:      

Report on Behalf of a Yes → Entity Name:      

Contractor without an
Approved EHSMS: No (Section 2) Contact Person:       Contact Number:      

2. Reportable Incident Information – Immediately Reportable to SRA – within 24 Hours

Serious Fatal

Health and Safety Incident:

Reportable Dangerous Occurrence
Reportable Occupational Fatality
(May select more than one)
Illness / Disease
Reportable Serious Injury

Environment - Moderate Environment - Major

Environmental Incident:
(May select more than one)
Spills / Releases /
Spills / Releases / Discharges to Releases / Discharges
Discharges to
Water, including Groundwater to Atmosphere
Land
Vegetation Removal Damage to Heritage
Harm to Animal Species
/ Harm Site

Other:      

3. Recordable Incident Information – Not Required to be Immediately Reported To SRA

For Entity Use Only – data to be submitted as part of EHS Performance Quarterly Report – Form E or E2

Minor / No Injury / Slight Moderate

Near Miss Lost Time Injury

Health and Safety Incident:

(May select more than one) First Aid Injury Medical Treatment Case

Equipment / Property Damage Restricted Workday Case

Environment - Minor

Environmental Incident:
(May select more than one)
Spills / Releases /
Spills / Releases / Discharges to Releases / Discharges
Discharges to
Water, including Groundwater to Atmosphere
Land
Vegetation Removal Damage to Heritage
Harm to Animal Species
/ Harm Site

Other:      

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FORM G
ENTITY EHS INCIDENT REPORTING

4. Incident Details:
Description of Circumstances
     
leading to the Incident:

Date of Incident: _      / _     / _      Time (24 hr):       :      

Incident Workplace Address:      

Incident Location on Site:      

Police Report Number: Medical Record / Certificate

           
(If applicable) Number: (If applicable)

5. Injured Person’s Personal Details (If applicable)

Name:       Occupation:      

Nationality:       Date of Birth:       /       /      

Passport Number:       Residency Visa Number:      

Contact Address:      

Contact Phone Number:       Gender: Male Female

Relationship to Injured Person: Direct Employee Other Person (eg. Visitor, Customer, Member of Public)

Part A - Declaration by Entity:

I declare that all information provided in this document is true, correct and complete.

Signature of the
Official
Authorized
Stamp:
Contact Person :

Date : _____ / _____ / _____

Official Use – Part A

Remarks :

Inspection / Incident Investigation Required by Sector Regulatory Authority

 Yes  No Remarks:

Entered into Database by:

Relevant Authority Stamp
Incident Record Number:

Name:

Signature:

Date: _____ / _____ / _____

Reviewed by:
Name:

Signature:

Date: _____ / _____ / _____

AD EHSMS RF - Version 2.0 – February 2012 Page 2 of 7

FORM G
ENTITY EHS INCIDENT REPORTING

Part B – Incident Investigation

To be completed and submitted to SRA as soon as practicable –
Maximum One Month from Date of Incident - For all Reportable Incidents

1. Injury Details

Abrasions / Bruising Traumatic Amputation Bite / Sting

Burn Concussion Crush / Internal Injury

Cuts/ Laceration / Open

Hearing Loss / Deafness Dislocation
Wound
Equipment / Property
Electric Shock Fracture
Damage

Foreign Body in Eye Foreign Body under Skin Hernia

Nature of Injury / Illness /
Damage: Musculoskeletal Disorder
Heat Related Illness Infectious Disease
- Chronic / RSI

Nerve / Spinal Cord Occupational Illness / Poisoning / Toxic Effect -

Injury Disease Ingestion

Poisoning / Toxic Effect -

Psychological (Stress) Respiratory Disease
Inhalation

Skin Irritation / Disease Strain / Sprain Other      

Animal Bit / Sting Biological Factors Cave-In or Collapse

Chemicals / Substances /
Drowning / Submersion Dust / Fumes / Gases
Radiation
Extreme Temperature /
Electricity Fall from Height
Fire

Hit by Moving Object /

Manual Handling Mental Stress
Crush / Vehicle
Mechanism of Injury / Illness:
Occupational Violence Penetrating Injury (needle stick, puncture wound)

Repetitive Motion Slip, Trip and Fall Sound and Pressure

Struck by Falling Object Other Unspecified Mechanism:      

Incident occurred during work-related travel, including traveling to

Journey Incident -
or from work. Refer – AD EHSMS Glossary of Terms.

Animal / Human Confined Space Environmental Conditions

Materials or Chemical
Fixed Machinery / Plant Infectious Agent
Substances

Agency / Source of Mobile Plant / Equipment Non-Powered Equipment / Tools / Appliances

Injury / Illness:
Powered Equipment / Road Transport /
Scaffolding or Ladders
Tools / Appliances Vehicles

Sharps / Scalpels /
Trench or Excavations Other      
Needles / Etc

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FORM G
ENTITY EHS INCIDENT REPORTING

Cervical Spine Ear Eye

Head /
Face (excluding eye) Forehead Mouth
Neck
Neck Nose Scalp

Abdomen Back Genitals

Trunk
Pelvis Spine Thorax
Fingers (other than
Clavicle (Collar Bone) Elbow
Thumbs)
Upper
Forearm Hand Shoulder
Extremity
Bodily Thumb Upper Arm Wrist
Location:
Ankle Buttocks Foot
Lower
Extremity Hip / Groin Knee Lower Leg

Thigh Toes

Arteries Brain Heart

Internal
Intestines Kidney Liver
Organs
Lungs Spleen Stomach

General Heat Related Occupational Illness Other:      

Other Relevant Incident Information:

Remarks:      

2. Risk Assessment:
Likelihood of Recurrence:      

Severity of Outcome:      

Level of Risk:      

3. Corrective Actions to Prevent Recurrence

Actions: By Whom: By When: Date Completed:

                       

                       

                       

4. Actions Complete:

Name:      
Title:      

Date:      
Signed (EHS Manager / Equivalent) :____________________________________

Feedback to person(s) involved.

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FORM G
ENTITY EHS INCIDENT REPORTING

Declaration by Injured Person (If Possible)

I declare that all information provided in this document is true, correct and complete.

Name of Injured Signature of Injured

Person or Person or
Representative: Representative:

Date : _____ / _____ / _____

Part B - Declaration by Entity:

I declare that all information provided in this document is true, correct and complete.

Signature of the
Official
Authorized
Stamp:
Contact Person :

Date : _____ / _____ / _____

Incident Reporting Progress

 Open  Closed

 Further evidence attached to report (eg. Photos, Drawings, SDS, Copy of Police Report, Detail Investigation Report, etc)

Official Use – Part B

Remarks :

Incident Investigation / Follow-up Required by Sector Regulatory Authority

 Yes  No Remarks:

Relevant Authority Stamp Entered into Database by:

Name:

Signature:

Date: _____ / _____ / _____

Reviewed by:

Name:

Signature:

Date: _____ / _____ / _____

Personal information will not be disclosed to other parties without your consent unless required to do so by law.

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FORM G
ENTITY EHS INCIDENT REPORTING

Entity EHS Incident Report Form (AD EHSMS Form G) - Guidance Notes
What is this Form used for?
This form has been designed to be used by entities nominated under the Abu Dhabi EHSMS as an
EHS Incident Report Form.
This form has primarily been designed to report certain EHS incidents to the concerned Sector
Regulatory Authority (AD EHSMS Form G Part A – Section 2).
The form can also be used to report and record all EHS incidents within the entity (AD EHSMS Form
G Part A – Section 3) - not all EHS incidents are reportable to concerned Sector Regulatory
Authorities.
Specific EHS incidents may require reporting to other relevant authorities (eg. Police, Ministry of
Labour, EAD, etc).

What Incidents need to be reported to the concerned Sector Regulatory Authority?

AD EHSMS Reportable Incidents include:
 Fatality;
 Reportable Serious Injury;
 Reportable Dangerous Occurrence;
 Reportable Occupational Illness / Disease; and
 Major or Moderate Pollution Incident (EAD reporting may be required).

Reporting Timeframes (Reportable Incidents)

The concerned Sector Regulatory Authority must be officially notified within 24 hours of an incident
occurring at a workplace which results in a reportable incident using Part A of this Form.
Incident investigation and report must be complete and submitted to the concerned Sector Regulatory
Authority within one month of the incident date using Part B of this Form.

Definitions - Full definitions of terms used in this document refer to the AD EHSMS RF - Glossary of Terms.
Occupational Illness or Injury:
Any of the work-related diseases listed in (Schedule No. 1 of Federal Law No. 8 of 1980 and EHS RI Mechanism
03 – EHS Performance and Incident Reporting Schedule C) or any other injury sustained by a worker during and
by reason of carrying out his duties. An injury may be considered as an occupational injury if it occurs at work or
arises from a work practice or the conditions in a workplace.

Occupational Injuries include the recurrence, aggravation or exacerbation of previous work-related injuries. For
example, if an employee has previously had a work-related knee injury and the injury happens again because of
work, the new injury may have to be reported.

Fatality:
Fatality is a death resulting from an injury or illness, regardless of the time intervening between injury and death.

Reportable Dangerous Occurrences - Schedule A of AD EHS RI – Mechanism 3.0

For detail definitions of the following incidents refer to Schedule A of AD EHS RI – Mechanism 3.0
 Explosion or Fire;
 Collapse of Equipment;
 Machinery Damage;
 Collapse of Building / Structure or Excavation;
 Overhead Electric Lines;
 Malfunction of Radiation Generating Equipment;
 Escape of Flammable Substances / Hazardous Substances; and
 Fall from Heights
FORM G
ENTITY EHS INCIDENT REPORTING

Serious Injuries that require Immediate Notification - Schedule B of AD EHS RI – Mechanism 3.0
An incident requiring reporting is classified as:
 the employee requiring medical treatment within 48 hours of exposure to a substance;
 an employee requiring immediate treatment as an in-patient in a hospital; and
 an employee requiring immediate medical treatment for:
 the loss of a distinct part or organ of the injured person’s body, including the amputation of any part of
an employee’s body;
 loss of consciousness and/or requiring resuscitation;
 a serious head injury;
 a serious eye injury, including loss of sight (temporary or permanent);
 the separation of skin from any underlying tissue (such as scalping or de-gloving);
 electric shock;
 a spinal injury;
 dislocation of the shoulder, hip, knee or spine;
 the loss of bodily function; and
 serious laceration.

Lost Time Injury

Lost Time Injury (LTI) is a work-related injury or illness that results an individual is unable to work on a
subsequent scheduled work day or shift.
Example: An employee is injured on the job on Tuesday. He was scheduled to work on Wednesday and
Thursday on regular time and Saturday on overtime. He was instructed to stay off work until Sunday, and did so.
This is a lost time injury. The employee missed three scheduled days of work (Wednesday Thursday, and
Saturday) and all three days are counted as lost workdays for this case.

Occupational Illness
Any work-related abnormal condition or disorder, other than an injury, which is mainly caused by exposure to
environmental factors associated with the employment.
It includes acute and chronic illness or diseases that may be caused by repetitive motion, inhalation, absorption,
ingestion or direct contact.
Whether a case involves a work-related injury or an Occupational Illness is determined by the nature of the
original event or exposure that caused the case, not by the resulting condition of the affected employee.
An injury results from a single event and cases resulting from anything other than a single event are considered
Occupational Illness.

Pollution Incident
An incident or set of circumstances during or as a consequence of which there is likely to be a leak spill or other
escape or deposit of a substance, as a result of which pollution has occurred, is occurring or is likely to occur. It
includes an incident or set of circumstances in which a substance has been placed or disposed of on premises.

Major Pollution Incident

Substances or materials have escaped the site causing significant pollution of adjoining areas which will require
containment, clean up and/or remediation involving other agencies and/or additional resources not available to
local site management. Irreversible or long term environmental impacts have occurred or are likely to occur to
the environment and/or there is a significant health risk to workers and/or the community. Significant, long-term
remediation and regulatory intervention will be required.

Moderate Pollution Incident

Substances or materials have escaped the site causing pollution of adjoining areas which may require
containment, clean up and/or remediation involving other agencies and/or additional resources not available to
local site management. Moderate reversible environmental impact has occurred or is likely to occur to the
environment and/or there is a moderate health risk to workers and/or the community. Moderate, medium-term
remediation and regulatory intervention may be required.