The Health and Safety Incident Report Form is a crucial document required under Nigerian workplace safety regulations, specifically designed to comply with the Factories Act Cap F1 LFN 2004 and related legislation. This form must be completed whenever a workplace incident occurs, whether resulting in injury, near-miss, property damage, or environmental impact. It captures essential information needed for internal investigation, regulatory reporting, insurance claims, and the development of preventive measures. The document serves multiple purposes: meeting legal reporting obligations, documenting incidents for future reference, supporting compensation claims, and contributing to organizational learning and risk management. It should be readily available in all workplaces and completed as soon as possible after an incident occurs.
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1. Incident Identification Details: Basic information including date, time, location, and reference number of the incident
2. Reporter Information: Details of the person completing the form including name, position, contact information
3. Affected Person(s) Information: Details of all persons involved in or affected by the incident, including employees, contractors, or visitors
4. Incident Description: Detailed account of what happened, including sequence of events and immediate actions taken
5. Injury/Damage Details: Specific information about any injuries sustained or property damage incurred
6. Witness Information: Names and contact details of any witnesses to the incident
7. Immediate Response Actions: Details of emergency response, first aid administered, or other immediate actions taken
8. Root Cause Analysis: Initial assessment of what caused the incident
9. Corrective Actions: Immediate and planned actions to prevent recurrence
10. Reporting Requirements: Checklist of regulatory bodies to be notified and confirmation of notifications made
1. Environmental Impact Assessment: Required when incident involves environmental contamination or hazardous materials
2. Equipment/Machinery Details: To be completed when incident involves equipment malfunction or machinery-related accidents
3. Third Party Involvement: Required when external contractors, visitors, or members of the public are involved
4. Medical Treatment Details: To be completed when medical treatment was required, including hospital/clinic information
5. Property Damage Assessment: Detailed section for incidents involving significant property or asset damage
6. Security Incident Details: Required when incident involves security breaches or criminal activity
1. Appendix A - Photographic Evidence: Template for attaching and labeling photographs of the incident scene, damages, or injuries
2. Appendix B - Witness Statement Form: Standard format for recording detailed witness accounts
3. Appendix C - Medical Report Template: Format for attaching medical reports and treatment details
4. Appendix D - Risk Assessment Matrix: Tool for assessing the severity and likelihood of similar incidents
5. Appendix E - Incident Scene Sketch: Template for drawing and describing the incident scene layout
6. Appendix F - Investigation Checklist: Comprehensive checklist for ensuring all necessary investigation steps are completed
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