Safety - Environment Incident Report Form



|INCIDENT DATE |INCIDENT TIME |REPORT DATE |REPORT TIME |

| | | | |

|INCIDENT OWNERSHIP | | |

|DIVISION |SUB-DIVISION |UNIT OR DEPT |

| | | |

|DESCRIPTION OF WHAT HAPPENED |

| |

|EXACT INCIDENT LOCATION |

| |

|On or Off BBC Site |Region/Area |Location |Sub-Area |

| | | | |

PERSON INVOLVED

|Does the person consent to details of their involvement in this Incident being passed to their union rep? |Yes / No |

|CATEGORY OF PERSON [(] |

|Employee |

|[ ] |

|Contractor |

|[ ] |

|Freelance |

|[ ] |

|Artist/Contributor |

|[ ] |

|Mem of. Public |

|[ ] |

| |

|NATURE OF INVOLVEMENT [(] |

|Witness |

|[ ] |

|First Person on Scene |

|[ ] |

|Other |

|[ ] |

| |

|PERSON’S NAME |

|Name: |Mr/Mrs/Miss/Ms |

| |First Name: |

| | |

| |Last Name: |

| | |

| | |

OTHER INFORMATION

|FM Manager in attendance (if applicable) | |

|Reported in Duty Log? |Yes |

| |[ ] |

| |No |

| |[ ] |

| |N/A |

| |[ ] |

| | |

|TYPE OF INCIDENT [(] |

|Breach of Limits/Licence Cond. |

|[ ] |

|Oil & Chemical Storage |

|[ ] |

|Spillage/Spillage Response |

|[ ] |

| |

|Waste Storage & Disposal |

|[ ] |

|Serious Public/Other Complaint |

|[ ] |

|Water Abstraction/Disposal |

|[ ] |

| |

|Third Parties and Supply Chain |

|[ ] |

|Smoke, Fumes & Odours |

|[ ] |

|Natural Envnment & Wildlife |

|[ ] |

| |

|Light Pollution |

|[ ] |

|Noise Nuisance |

|[ ] |

|Other |

|[ ] |

| |

|If “Other” please describe: |

| |

| |

|Is this a reportable incident? |Yes |

| |[ ] |

| |No |

| |[ ] |

| |Unknown |

| |[ ] |

| | |

|If "Yes" which agency | |

|What are the actual or foreseeable potential consequences known at this time? [(] |

|Prosecution |

|[ ] |

|Enforcement Notice (Imp/Proht) |

|[ ] |

|Civil Claim |

|[ ] |

| |

|Clean-up/Restoration |

|[ ] |

|Breach of Licence Requirements |

|[ ] |

|Adverse Publicity/Reaction |

|[ ] |

| |

|Adverse Customer Reaction |

|[ ] |

|Contamination of Water |

|[ ] |

|Habitat or Species |

|[ ] |

| |

|Health Effects |

|[ ] |

| |

| |

| |

| |

| |

|Please provide any other relevant information |

| |

|What immediate actions have been taken? |

| |

|INCIDENT REPORTED BY |

|Name |Telephone No. |Date |

| | | |

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my risks

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