The Employee Incident Report Form is a crucial document required under Dutch workplace safety legislation, specifically designed to comply with the Working Conditions Act (Arbeidsomstandighedenwet) and related regulations. This form must be used whenever a workplace incident, accident, or near-miss occurs, serving as an official record for both internal documentation and potential external reporting requirements. It captures detailed information about the incident, including circumstances, involved parties, witness accounts, and immediate actions taken, while adhering to GDPR privacy requirements for handling personal data. The document plays a vital role in risk management, insurance claims, legal compliance, and the continuous improvement of workplace safety measures. It should be completed as soon as possible after an incident occurs, with copies maintained according to Dutch record-keeping requirements.
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1. Incident Reporter Details: Information about the person filling out the form, including name, position, and contact details
2. Incident Basic Information: Date, time, and location of the incident
3. Affected Persons: Details of all persons involved in or affected by the incident, including employees, contractors, visitors
4. Incident Description: Detailed narrative of what happened, including the sequence of events
5. Immediate Actions Taken: Description of emergency responses and immediate actions taken following the incident
6. Injuries and Damage: Description of any injuries to persons or damage to property/equipment
7. Witness Information: Names and contact details of any witnesses to the incident
8. Report Completion: Date of report completion, signature of reporter, and immediate supervisor's acknowledgment
1. Medical Treatment Details: To be included when medical attention was required, including first aid or professional medical care
2. Environmental Impact: To be included for incidents involving environmental spillage or damage
3. Equipment/Machinery Involved: To be included when the incident involved workplace equipment or machinery
4. External Authority Notification: To be included when the incident required reporting to external authorities (e.g., Labor Inspectorate)
5. Risk Assessment Review: To be included for serious incidents requiring review of existing risk assessments
6. Photos and Visual Evidence: To be included when photographic or visual evidence is available
1. Incident Scene Diagram: Template for sketching the location and setup where the incident occurred
2. Witness Statement Form: Standard template for collecting detailed witness accounts
3. Privacy Notice: GDPR-compliant notice explaining how personal data in the report will be processed
4. Investigation Checklist: Standard checklist for ensuring all necessary information has been collected
5. Follow-up Actions Log: Template for recording subsequent actions, investigations, and preventive measures
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