Report an accident at work (online form)

Please use this form to report an accident, incident or ill-health at work. This information is required by law.

Is this incident reportable?
If you are unsure, please read this guidance on accident reporting. [379kb]
Can I report the accident, disease, dangerous occurrence or incident in any other way?
You can download a printable version of the accident report form. [253kb] - some accidents must be notified by phone as soon as practicable on 01481 220010, followed by the electronic or paper report form.

All sections of the form must be completed unless specified.
This information is required under Section 9 of the Health and Safety at Work (General) (Guernsey) Ordinance, 1987. Completing this form does not constitute an admission of liability of any kind, either by the person making the report or any other person.
If more than one person was injured as a result of an accident, please complete a separate report for each person.
A - What are you reporting?
1. Subject of Report*
HSE must be notified immediately of fatalities, major specified injuries and dangerous occurrences by phone on 01481 220010 or email hse@gov.gg. Out of office hours, Guernsey Police must be informed on 01481 222222.
If HSE was advised of this incident
1. Name of person advised
2. Date advised (DD/MM/YYYY)
3. Time advised
4. How was HSE advised of incident
  
  Telephone
  
  Email
  
  Via Guernsey Police
B - Information about the employer or responsible person
1. This form must be completed in full by the employer or responsible person (as is required by law).
2. Company, employer or responsible person's name*
3. Address of company or employer (please include the postcode)*
4. Nature of trade, business or undertaking*
5. Total number of employees*
6. Name and telephone number of person to contact about this accident*
C - Date, time and place of incident
1. Date of accident (DD/MM/YYYY):*
2. Time*
3. Name and address if different from above
4. Normal activity carried on there
If you are reporting a dangerous occurrence, please continue to section G.
D - The person injured or affected by the disease
1. Full name
2. Status
  
  Employee
  
  Self-employed
  
  Trainee or apprentice
  
  Any other person
3. Trade, occupation or job title
4. Nature of injury or condition and the part of the body affected. in case of a disease, the name or schedule number of the disease.
5. Total time off work / Total time unable to perform normal duties
If you are reporting a disease, please continue to section G.

St Peter Port & St Sampson

All Other Parishes

Report an accident at work (online form)

Is this incident reportable?

Can I report the accident, disease, dangerous occurrence or incident in any other way?