HSE Report - Cathodic

Incident Date & Time *

Date

Time

Persons Affected or Injured

Name *

First

Last

Location / Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Project, Works Order or Activity *

Department or Area incident occured *

Occupation *

What are you reporting? *

Harm (or potential for harm) *

Examples: Fatal or Major: Road traffic accident / incident involving others Serious: Injury causing a hospital visit (not like threatening) Minor: (First Aid required but not serious) Asset Damage: Any damage to a company asset

Brief Description of Events *

Details of what happened, when, where, and emergency action taken

Immediate Actions Taken *

This could include things like, contacted 1st Aider, notified other team members, advising other staff on the status of the work area you left etc

Details of any Witness (es)

Please share any images taken of the incident

Click or drag files to this area to upload. You can upload up to 2 files.

If you have any further images of the incident, please share them directly with your Line Manager or Members of the compliance team

Any other information you feel is relevent?

First Aid Support

Was First Aid /required? *

Is the person recording this, the same person detailed above *

Name *

First

Last

Name of First Aider, or persons completing the form

Are you a company First Aider? *

Yes
No

How would you describe the incident or accident *

Tyoe of Treatment or Outcome *

Minor First Aid Case would be where local first aid was adequate such as a plaster on a cut MTC would be where a visit to a medical professional was required such as A&E

Do you feel a further investigation is required? *

Yes
No
Unsure