Accident Reporting - GCC Facilities Management plc

Please complete this form to make an Accident/Near Miss/Damage to Property Report.

You can also make a report by emailing: HealthandSafety@gccfm.com.

Name of Injured Person/Description of Damage to Property

Position/role within the company

Injured Person's Email Address

Injured Person's Contact Number

Name of Person Making This Report

Position/role within the company

Reporting Person's Email Address

Reporting Person's Contact Number

When did the accident happen? (Date)

When did the accident happen? (Time)

What damage occurred and what injuries were sustained (if any)?

Where did the accident happen? (State room or location)?

How did the accident/incident happen?(Give cause if you can)?

What activities/tasks were being carried out at the time of the accident?

I confirm that the information provided is correct to the best of my knowledge.