Safety Incident Notification Form

Submitted from the NEOM Proponent Organization (PO) to the NEOM LP&FS PS for all work-related incidents. Refer
to NEOM-NLF-PRC-008 for more details.
Reporting To: Reporting Date: (DD/MM/YYYY)
1. Reporting organization Information: Incident No. (for official use by PO Safety Department)
Name of organization:
Proponent / Sector / Department:
Registration Number:
Address of organization:
Authorized Contact Person: Email Address:
Telephone Number: Mobile Number:

2. Reporting on behalf of a Directly employed Contractor

☐ Yes ☐ No

Name of Contractor:
Type of Business:
Address & Phone Number:

3. Does the Incident fall under NEOM jurisdiction or involve NEOM employee or NEOM’s contractor employee?
☐ Yes ☐ No

If Yes: Continue with the Incident Notification Report

If No: Ceases Incident Notification Report
If Unsure: Contact your Proponent Organization Safety Department or NEOM LP&FS
4. Incident Information
DD/MM/YYYY Time (24 hr):

Type of Incident: ☐ Fatality ☐ Injury ☐ Occupational illness ☐ Fire

Other ☐ Equipment / Property

☐ Loss Time Injury ☒ Medical Treatment Case ☐ First Aid Cases
Consequences Damage
resulting from this Other Consequence:
incident

Incident Classification ☐ High Potential

☐ Major ☐ Moderate ☐ Minor ☐ Near Miss
Near Miss
Incident Description:
(Attach additional pages if required)

Add names of witnesses and contact

information.

What could have been done to prevent

the incident?

Describe what led up to the injury or

fatality.

Were safety regulations in place and

used?
Incident Location on Work Site:
Incident Workplace Address:
(If no address is available, provide GPS
Coordinates)
Where incident occurred: ☐ Worksite ☐ Accommodation ☐ Transportation
Applicable Reports: ☐ Police ☐ Medical ☐ Other (Specify)

DOCUMENT CODE : NEOM-NLF-PRC-008-FRM-001 REVISION CODE0.1.00 PAGE 1 OF 2

 Attached: ☐ Yes ☐ No ☐ Yes ☐ No ☐ Yes ☒ No

7. Injured Person’s Personal Details (For Injuries):

In case of an incident with more than one injured person, complete the information for each person using separate forms
Name: Occupation:
Relationship with Organization: ☐ Organization Employee ☐ Contractor Employee ☐ Other Person (e.g. Visitor,)
Nationality: Date of Birth:
Passport / Iqama Number: Length of Service: __ Years __ Months
Contact Phone Number: Gender: ☐ Male ☐ Female

8. Actions Taken Immediately after the Incident:

(Attach additional pages if more space is required)
No. Actions Responsibility Status
1.
2.
3.

Declaration by Reporting Proponent Organization:

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

Signature of the
Official
Authorized
Stamp:
Contact Person:

Date:
(DD/MM/YYYY)

Official Use by NEOM Proponent Organization Safety Department

Requires Reporting to Third ☐ Yes ☐ No Requires: Investigation / Follow-up ☒ Yes ☒ No
Party:
Remarks:

NEOM Proponent Organization

Submitted by:
Name: Position:

Signature:

Date: (DD /MM /YYYY)

Received and acknowledged by: Position:

Name:

Signature:

Date: (DD /MM /YYYY)

Distribution:
1. E&TSD NEOM Loss Prevention and Fire Safety Public Safety (LP&FS PS)
2. NEOM Proponent Organization Head

DOCUMENT CODE : NEOM-NLF-PRC-008-FRM-001 REVISION CODE0.1.00 PAGE 2 OF 2