The Health and Safety Incident Report Form is a crucial document required under Dutch workplace safety legislation, specifically the Working Conditions Act (Arbowet) and associated regulations. It must be used to report any workplace incident, accident, near-miss, or dangerous occurrence that could affect employee health and safety. The form serves multiple purposes: documenting incidents for legal compliance, facilitating thorough investigation of root causes, identifying necessary preventive measures, and maintaining records for regulatory authorities and insurance purposes. It contains sections for recording incident details, affected persons, witness statements, immediate actions taken, and follow-up measures. The document is particularly important in the Netherlands where employers have strict obligations regarding workplace safety and incident reporting.
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1. Incident Identification: Basic details including date, time, location, and reference number of the incident
2. Reporter Information: Details of the person completing the report including name, role, and contact information
3. Incident Details: Description of what happened, including the sequence of events and immediate actions taken
4. Affected Persons: Information about all persons involved in or affected by the incident, including employees, contractors, or visitors
5. Injury/Illness Details: Nature and severity of any injuries or illnesses resulting from the incident
6. Immediate Response: Actions taken immediately after the incident, including first aid or emergency services involvement
7. Witness Information: Details of any witnesses to the incident
8. Root Cause Analysis: Investigation into the underlying causes of the incident
9. Corrective Actions: Measures taken or planned to prevent recurrence
10. Reporting Requirements: Confirmation of statutory reporting obligations (e.g., to Dutch Labor Inspectorate if applicable)
1. Environmental Impact: For incidents involving environmental effects or hazardous substance releases
2. Equipment/Property Damage: Details of any damage to equipment, facilities, or other property
3. Production/Operations Impact: Assessment of impact on business operations and any downtime
4. Third Party Involvement: Details of any contractors, visitors, or members of the public involved
5. Cost Analysis: Assessment of financial impact including property damage, lost time, and other costs
6. Media/External Communications: For significant incidents requiring external communication management
1. Incident Scene Photographs: Visual documentation of the incident scene and any relevant evidence
2. Witness Statements: Detailed statements from witnesses on separate forms
3. Medical Reports: Copies of relevant medical assessments or treatment records
4. Risk Assessment: Copy of relevant risk assessment and safe working procedures
5. Training Records: Copies of relevant training certificates or records for involved persons
6. Equipment Inspection Records: Recent inspection or maintenance records for involved equipment
7. Investigation Findings: Detailed investigation report if conducted separately
8. Action Plan: Detailed corrective action plan with timelines and responsibilities
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