The Critical Incident Report Form serves as an essential documentation tool for organizations operating in Nigeria, designed to capture detailed information about significant events that may impact safety, operations, or legal compliance. This document is required whenever an incident occurs that results in or could have resulted in injury, property damage, operational disruption, or other significant consequences. It aligns with Nigerian regulatory requirements, including the Labour Act, Factories Act, and Employee's Compensation Act, while incorporating best practices in incident documentation. The form enables organizations to maintain accurate records for legal purposes, insurance claims, risk management, and continuous improvement of safety protocols. It should be completed as soon as possible after an incident occurs, typically within 24 hours, to ensure accuracy of information and timely reporting to relevant authorities when required.
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1. Incident Reporter Details: Information about the person completing the form including name, position, contact details, and relationship to the incident
2. Incident Overview: Basic information including date, time, location, and type of incident
3. Incident Details: Detailed description of what happened, including sequence of events and immediate actions taken
4. Persons Involved: Details of all individuals involved in or affected by the incident, including staff, patients, visitors, or witnesses
5. Injuries/Damage Assessment: Description of any injuries sustained or property damage incurred
6. Immediate Actions Taken: Steps taken immediately following the incident to secure safety, provide first aid, or prevent further damage
7. Notifications Made: List of all parties notified about the incident (e.g., management, emergency services, regulatory bodies)
8. Risk Assessment: Assessment of the severity and likelihood of recurrence
9. Verification and Sign-off: Signatures and dates from the reporter and reviewing manager/supervisor
1. Environmental Factors: Used when environmental conditions contributed to the incident, detailing weather, lighting, facility conditions, etc.
2. Equipment Involved: Required when machinery, medical equipment, or other technical equipment was involved in the incident
3. Witness Statements: To be included when there are witnesses to the incident who can provide additional perspectives
4. Medical Response Details: Required for incidents involving injury or medical emergency
5. Security Involvement: Used when security personnel were involved or security measures were implemented
6. Media/External Communications: Required for high-profile incidents that may attract media attention or require external communication
7. Financial Impact: Used when there are significant costs or financial implications associated with the incident
1. Appendix A - Photographic Evidence: Template for logging and attaching photographs of the incident scene, injuries, or damage
2. Appendix B - Witness Statement Form: Standardized form for collecting detailed witness accounts
3. Appendix C - Body Map: Diagram for marking location and type of injuries
4. Appendix D - Scene Diagram: Template for sketching the incident scene and relevant details
5. Appendix E - Investigation Checklist: Standardized checklist for ensuring all necessary steps have been completed
6. Appendix F - Follow-up Action Plan: Template for documenting required corrective actions and preventive measures
7. Appendix G - Related Documents Log: List of all associated documents, reports, or correspondence related to the incident
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