FORM G
ENTITY EHS INCIDENT REPORTING
Part A – Incident Notification
To be submitted to the Sector Regulatory Authority within 24 hours for all Reportable Incidents
1. General Information
Name of Entity:
Registration
Number:
Classification Code:
Address of Entity:
Authorized Contact Person:
Email Address:
Telephone Number:
Mobile Number:
Report on Behalf of a
Contractor without an
Approved EHSMS:
Yes
→

No (Section 2)
Entity Name:
Contact Person:
Contact Number:
2. Reportable Incident Information – Immediately Reportable to SRA – within 24 Hours
Serious
Health and Safety Incident:
Fatal
Reportable Dangerous Occurrence
Reportable Occupational
Illness / Disease
(May select more than one)
Fatality
Reportable Serious Injury
Environment - Moderate
Environmental Incident:
(May select more than one)
Environment - Major
Spills / Releases /
Discharges to
Land
Spills / Releases / Discharges to
Water, including Groundwater
Releases / Discharges
to Atmosphere
Vegetation
Removal / Harm
Harm to Animal Species
Damage to Heritage
Site
Other:
3. Recordable Incident Information – Not Required to be Immediately Reported To SRA
For Entity Use Only – data to be submitted as part of EHS Performance Quarterly Report – Form E or E2
Minor / No Injury / Slight
Moderate
Near Miss
Lost Time Injury
First Aid Injury
Medical Treatment Case
Equipment / Property Damage
Restricted Workday Case
Health and Safety Incident:
(May select more than one)
Environment - Minor
Environmental Incident:
(May select more than one)
Spills / Releases /
Discharges to
Land
Spills / Releases / Discharges to
Water, including Groundwater
Releases / Discharges
to Atmosphere
Vegetation
Removal / Harm
Harm to Animal Species
Damage to Heritage
Site
Other:
AD EHSMS RF - Version 2.0 – February 2012
Page 1 of 7
FORM G
ENTITY EHS INCIDENT REPORTING
4. Incident Details:
Description of Circumstances
leading to the Incident:
Date of Incident:
_
/_
/_
Time (24 hr):
:
Incident Workplace Address:
Incident Location on Site:
Police Report Number:
(If applicable)
Medical Record / Certificate
Number: (If applicable)
5. Injured Person’s Personal Details (If applicable)
Name:
Occupation:
Nationality:
Date of Birth:
Passport Number:
Residency Visa Number:
/
/
Contact Address:
Contact Phone Number:
Gender:
Relationship to Injured Person:
Direct Employee
Male
Female
Other Person (eg. Visitor, Customer, Member of Public)
Part A - Declaration by Entity:
I declare that all information provided in this document is true, correct and complete.
Signature of the
Authorized
Contact Person :
Date :
Official
Stamp:
_____ / _____ / _____
Official Use – Part A
Remarks :
Inspection / Incident Investigation Required by Sector Regulatory Authority

Yes

No
Remarks:
Entered into Database by:
Relevant Authority Stamp
Incident Record Number:
Name:
Signature:
Date:
_____ / _____ / _____
Reviewed by:
Name:
Signature:
Date:
AD EHSMS RF - Version 2.0 – February 2012
_____ / _____ / _____
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FORM G
ENTITY EHS INCIDENT REPORTING
Part B – Incident Investigation
To be completed and submitted to SRA as soon as practicable –
Maximum One Month from Date of Incident - For all Reportable Incidents
1. Injury Details
Nature of Injury / Illness /
Damage:
Abrasions / Bruising
Traumatic Amputation
Bite / Sting
Burn
Concussion
Crush / Internal Injury
Cuts/ Laceration / Open
Wound
Hearing Loss / Deafness
Dislocation
Electric Shock
Equipment / Property
Damage
Fracture
Foreign Body in Eye
Foreign Body under Skin
Hernia
Heat Related Illness
Infectious Disease
Musculoskeletal Disorder
- Chronic / RSI
Nerve / Spinal Cord
Injury
Occupational Illness /
Disease
Poisoning / Toxic Effect Ingestion
Poisoning / Toxic Effect Inhalation
Psychological (Stress)
Respiratory Disease
Skin Irritation / Disease
Strain / Sprain
Other
Animal Bit / Sting
Biological Factors
Cave-In or Collapse
Chemicals / Substances
/ Radiation
Drowning / Submersion
Dust / Fumes / Gases
Extreme Temperature /
Fire
Electricity
Fall from Height
Hit by Moving Object /
Crush / Vehicle
Manual Handling
Mental Stress
Occupational Violence
Penetrating Injury (needle stick, puncture wound)
Repetitive Motion
Slip, Trip and Fall
Struck by Falling Object
Other Unspecified Mechanism:
Mechanism of Injury / Illness:
Journey Incident -
Agency / Source of
Injury / Illness:
Incident occurred during work-related travel, including traveling to
or from work. Refer – AD EHSMS Glossary of Terms.
Animal / Human
Confined Space
Fixed Machinery / Plant
Infectious Agent
Mobile Plant / Equipment
Non-Powered Equipment / Tools / Appliances
Powered Equipment /
Tools / Appliances
Sharps / Scalpels /
Needles / Etc
Version 2.0
Sound and Pressure
Road Transport /
Vehicles
Trench or Excavations
Environmental Conditions
Materials or Chemical
Substances
Scaffolding or Ladders
Other
Page 3 of 7
FORM G
ENTITY EHS INCIDENT REPORTING
Head /
Neck
Cervical Spine
Ear
Eye
Face (excluding eye)
Forehead
Mouth
Neck
Nose
Scalp
Abdomen
Back
Genitals
Pelvis
Spine
Thorax
Clavicle (Collar Bone)
Elbow
Fingers (other than
Thumbs)
Forearm
Hand
Shoulder
Thumb
Upper Arm
Wrist
Ankle
Buttocks
Foot
Hip / Groin
Knee
Lower Leg
Thigh
Toes
Arteries
Brain
Heart
Intestines
Kidney
Liver
Lungs
Spleen
Stomach
Heat Related
Occupational Illness
Other:
Trunk
Upper
Extremity
Bodily
Location:
Lower
Extremity
Internal
Organs
General
Other Relevant Incident Information:
Remarks:
2. Risk Assessment:
Likelihood of Recurrence:
Severity of Outcome:
Level of Risk:
3. Corrective Actions to Prevent Recurrence
Actions:
By Whom:
By When:
Date Completed:
4. Actions Complete:
Name:
Signed (EHS Manager / Equivalent) :____________________________________
Title:
Date:
Feedback to person(s) involved.
Version 2.0
Page 4 of 7
FORM G
ENTITY EHS INCIDENT REPORTING
Declaration by Injured Person (If Possible)
I declare that all information provided in this document is true, correct and complete.
Name of Injured
Person or
Representative:
Date :
Signature of Injured
Person or
Representative:
_____ / _____ / _____
Part B - Declaration by Entity:
I declare that all information provided in this document is true, correct and complete.
Signature of the
Authorized
Contact Person :
Date :
Official
Stamp:
_____ / _____ / _____
Incident Reporting Progress



Open
Closed
Further evidence attached to report (eg. Photos, Drawings, SDS, Copy of Police Report, Detail Investigation Report, etc)
Official Use – Part B
Remarks :
Incident Investigation / Follow-up Required by Sector Regulatory Authority

Yes

Relevant Authority Stamp
No
Remarks:
Entered into Database by:
Name:
Signature:
Date:
_____ / _____ / _____
Reviewed by:
Name:
Signature:
Date:
_____ / _____ / _____
Personal information will not be disclosed to other parties without your consent unless required to do so by law.
Version 2.0
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FORM G
ENTITY EHS INCIDENT REPORTING
Entity EHS Incident Report Form (AD EHSMS Form G) - Guidance Notes
What is this Form used for?
This form has been designed to be used by entities nominated under the Abu Dhabi EHSMS as an
EHS Incident Report Form.
This form has primarily been designed to report certain EHS incidents to the concerned Sector
Regulatory Authority (AD EHSMS Form G Part A – Section 2).
The form can also be used to report and record all EHS incidents within the entity (AD EHSMS Form
G Part A – Section 3) - not all EHS incidents are reportable to concerned Sector Regulatory
Authorities.
Specific EHS incidents may require reporting to other relevant authorities (eg. Police, Ministry of
Labour, EAD, etc).
What Incidents need to be reported to the concerned Sector Regulatory Authority?
AD EHSMS Reportable Incidents include:

Fatality;

Reportable Serious Injury;

Reportable Dangerous Occurrence;

Reportable Occupational Illness / Disease; and

Major or Moderate Pollution Incident (EAD reporting may be required).
Reporting Timeframes (Reportable Incidents)
The concerned Sector Regulatory Authority must be officially notified within 24 hours of an incident
occurring at a workplace which results in a reportable incident using Part A of this Form.
Incident investigation and report must be complete and submitted to the concerned Sector Regulatory
Authority within one month of the incident date using Part B of this Form.
Definitions - Full definitions of terms used in this document refer to the AD EHSMS RF - Glossary of Terms.
Occupational Illness or Injury:
Any of the work-related diseases listed in (Schedule No. 1 of Federal Law No. 8 of 1980 and EHS RI Mechanism
03 – EHS Performance and Incident Reporting Schedule C) or any other injury sustained by a worker during and
by reason of carrying out his duties. An injury may be considered as an occupational injury if it occurs at work or
arises from a work practice or the conditions in a workplace.
Occupational Injuries include the recurrence, aggravation or exacerbation of previous work-related injuries. For
example, if an employee has previously had a work-related knee injury and the injury happens again because of
work, the new injury may have to be reported.
Fatality:
Fatality is a death resulting from an injury or illness, regardless of the time intervening between injury and death.
Reportable Dangerous Occurrences - Schedule A of AD EHS RI – Mechanism 3.0
For detail definitions of the following incidents refer to Schedule A of AD EHS RI – Mechanism 3.0


Explosion or Fire;

Machinery Damage;


Collapse of Building / Structure or Excavation;

Malfunction of Radiation Generating Equipment;


Escape of Flammable Substances / Hazardous Substances; and
Collapse of Equipment;
Overhead Electric Lines;
Fall from Heights
FORM G
ENTITY EHS INCIDENT REPORTING
Serious Injuries that require Immediate Notification - Schedule B of AD EHS RI – Mechanism 3.0
An incident requiring reporting is classified as:

the employee requiring medical treatment within 48 hours of exposure to a substance;

an employee requiring immediate treatment as an in-patient in a hospital; and

an employee requiring immediate medical treatment for:

the loss of a distinct part or organ of the injured person’s body, including the amputation of any part of
an employee’s body;

loss of consciousness and/or requiring resuscitation;

a serious head injury;

a serious eye injury, including loss of sight (temporary or permanent);

the separation of skin from any underlying tissue (such as scalping or de-gloving);

electric shock;

a spinal injury;

dislocation of the shoulder, hip, knee or spine;

the loss of bodily function; and

serious laceration.
Lost Time Injury
Lost Time Injury (LTI) is a work-related injury or illness that results an individual is unable to work on a
subsequent scheduled work day or shift.
Example: An employee is injured on the job on Tuesday. He was scheduled to work on Wednesday and
Thursday on regular time and Saturday on overtime. He was instructed to stay off work until Sunday, and did so.
This is a lost time injury. The employee missed three scheduled days of work (Wednesday Thursday, and
Saturday) and all three days are counted as lost workdays for this case.
Occupational Illness
Any work-related abnormal condition or disorder, other than an injury, which is mainly caused by exposure to
environmental factors associated with the employment.
It includes acute and chronic illness or diseases that may be caused by repetitive motion, inhalation, absorption,
ingestion or direct contact.
Whether a case involves a work-related injury or an Occupational Illness is determined by the nature of the
original event or exposure that caused the case, not by the resulting condition of the affected employee.
An injury results from a single event and cases resulting from anything other than a single event are considered
Occupational Illness.
Pollution Incident
An incident or set of circumstances during or as a consequence of which there is likely to be a leak spill or other
escape or deposit of a substance, as a result of which pollution has occurred, is occurring or is likely to occur. It
includes an incident or set of circumstances in which a substance has been placed or disposed of on premises.
Major Pollution Incident
Substances or materials have escaped the site causing significant pollution of adjoining areas which will require
containment, clean up and/or remediation involving other agencies and/or additional resources not available to
local site management. Irreversible or long term environmental impacts have occurred or are likely to occur to
the environment and/or there is a significant health risk to workers and/or the community. Significant, long-term
remediation and regulatory intervention will be required.
Moderate Pollution Incident
Substances or materials have escaped the site causing pollution of adjoining areas which may require
containment, clean up and/or remediation involving other agencies and/or additional resources not available to
local site management. Moderate reversible environmental impact has occurred or is likely to occur to the
environment and/or there is a moderate health risk to workers and/or the community. Moderate, medium-term
remediation and regulatory intervention may be required.