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Report (near) accident

Dit bericht is ook beschikbaar in: Nederlands (Dutch) English

Form for reporting an accident or near miss accident (eng)

Concerns notification of:

Work accident

Near miss work accident

Dangerous situation

Are you a victim or reporter of the (near) accident or dangerous situation?

Victim

Reporter

First name

Name

Company:

Office/space

Phone number

Location (near) accident or dangerous situation:

Date and time (near) accident or dangerous situation:

Short description (Mention things like nature of work/activities during the accident)

Is there case of injury or (possible) exposure?

Yes

No

Assistance provided by:

N/A

ER

First aid

Coworker(s)

Hospital

Different

Name caregiver or hospital

Nature of assistance:

Has absenteeism occurred as a result of the accident?

No

Yes

(still) unknown

If so, how many days?

What measures were taken immediately after the (near) accident or detection of the dangerous situation?

What measures can be taken to prevent the (near) accident/dangerous situation in the future?

Can possible damage be recovered?

N/A

No

Yes

Date:

Room for comments/additions:

Dit bericht is ook beschikbaar in: Nederlands (Dutch) English

Vind ons

Adres
Smedestraat 2,
6411 CR Heerlen

Openingstijden bewoners
Maandag—vrijdag: 06:30–23:00
Zaterdag & zondag: GESLOTEN

Openingstijden bezoekers
Maandag—vrijdag: 09:00–18:00
Zaterdag & zondag: GESLOTEN

Nederlands (Dutch)
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