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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