Major environmental Incident arising from a Safety Incident. (Note: PON1 reporting is still a requirement. The ROGI form is additional in the event of a Major environmental incident)
Implementing Regulation Section J: A Major Environmental Incident
54.Section J1
General information
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Name of contractor (if applicable)
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Enter name of contractor
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55.Section J2
Description of circumstances, consequences of event and emergency response
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Indicate the system that failed and provide a description of the circumstances of the event / describe what has happened. What are or are likely to be the significant adverse effects on the environment?
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Enter description
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56.Section J3
Preliminary direct and underlying causes (within 10 working days of the event)
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Enter causes
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57.Section J4
Initial lessons learned and preliminary recommendations to prevent recurrence of similar events (within 10 working days of the event)
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Enter lessons learned and recommendations
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End of Part J Detailed Report
Other reportable injuries, Diseases and Dangerous Occurrences: (Over Seven day injuries, Occupational Diseases; Exposure to Carcinogens, Mutagens and Biological Agents: Diseases Offshore; Diving Operations; Dropped Objects; Fall into Water; Lifting equipment; Biological agents; Radiation; Breathing Apparatus; Pipelines or Pipeline Works)
RIDDOR 2013 4(2) Over-Seven-Day Injuries to Workers/8. & Schedule 1 Part 1 2.(1)Occupational Diseases/9. Exposure to Carcinogens, Mutagens and Biological Agents/10. & Schedule 1 Part 1 2.(1) Diseases Offshore/ Diving Operations Schedule 2 13-17
Dangerous Occurrence Form: RIDDOR Schedule 2 Part 6 80. Dropped Objects/ 87. Fall into Water
59.Accident Report
About the kind of accident
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Select the kind of accident that best describes the incident
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Choose kind of accident
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If a fall from height- how high was the fall (to the nearest meter)
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Enter measurement
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Work process involved in the incident
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Choose a work process
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Main factor involved in the incident
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Choose a main factor
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Describe what happened
(give as much detail as you can, including i) the events that led to the incident ii) the operation or activity in progress. Describe any action taken to prevent similar incidents occurring.)
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Enter description
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About the Injured person
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Name
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Family name
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Address Line 1
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Enter address line1
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Address Line 2
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Enter address line 2
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Address Line 3
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Enter address line 3
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Town
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Enter Town
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County
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Enter county
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Post Code
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Enter postcode
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Phone No
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Enter phone number
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Gender
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☐
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Male
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☐
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Female
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Age
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Enter age
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Injured person’s employment status
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Was the injured person
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☐
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One of your employees?
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☐
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On a training scheme?
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☐
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Employed by someone else?
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☐
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On work experience?
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☐
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Self-employed and at work?
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☐
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Member of the public?
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Details if the person was on a training scheme / employed by someone else
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Enter details
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About the severity of the person’s injuries
Please refer to the help for guidance on severity of injury
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Please help us determine the severity of the injury
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Was the injury fatal
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☐
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Yes
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☐
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No
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If no, was the worker’s injury one of these (as specified under RIDDOR):
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bone fracture excluding finger, thumb or toe
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amputation of arm, hand, finger, thumb, leg, foot or toe
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blinding or permanent sight reduction
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crush injuries leading to brain damage or internal organ damage
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serious burns
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scalping requiring hospital treatment
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loss of consciousness caused by head injury or asphyxia
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injuries associated with working in an enclosed space leading to hypothermia or heat-induced illness, resuscitation, hospitalisation for over 24 hours
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☐
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Yes
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☐
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No
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If no, the injury prevented the worker from carrying out their routine work for more than 7 days
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|
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☐
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Yes
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|
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The injury was to a member of the public taken directly to hospital / injured on hospital premises
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☐
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Yes
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About the person’s injuries
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Injuries
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Choose an injury
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Parts of the body Affected
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Choose the part of the body affected
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60.Dangerous Occurrence Report
Type of dangerous occurrence
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Choose an occurrence
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Describe what happened
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Enter description
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61.Occupational Disease Report
Affected person’s name
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Enter name
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Gender
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☐
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Male
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☐
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Female
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Age
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Enter age
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What was the person’s occupation or job title
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Enter occupation or job title
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Work Status
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Enter work status
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Date the disease was diagnosed / confirmed
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Enter date
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Where was the disease contracted?
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Enter location
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Disease category diagnosed
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Choose a disease category
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Specify the diagnosed disease
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Enter disease
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Details of the work activity that led to the disease
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Enter work related cause
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End of Part K Detailed Report
62.Part L Detailed Report
Death or Loss of a Person Pursuant to MAR Regulation 21B (Note: although provided within the ROGI Form this must be printed and sent to the Registrar General of Shipping and Seamen)
Form to be Completed in respect of the death or loss of a person pursuant to Regulation 21B – Offshore Installations and Pipelines Works (Management and Administration) Regulations 1995
Section L only is to be printed out and the form is to be sent to the :
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Registrar General of Shipping and Seamen
Anchor Court
Keen Road
Cardiff
CF24 5JW
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PART 1
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Name or other designation of offshore installation
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Enter name of offshore installation
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Date of death or loss
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Enter date
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Place of death or loss(a)
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Enter location
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Full name of deceased or person lost(b)
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Enter name
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Gender
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☐
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Male
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☐
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Female
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Age
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Enter age
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Capacity in which person deceased or lost was engaged or other reason for presence at the installation
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Enter details
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Cause of death or loss(c)
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Enter cause
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I certify that the particulars entered above are true to the best of my knowledge and belief:
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Signature of installation manager furnishing information
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Name of installation manager furnishing information(b)
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Enter name
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Status of signatory
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Enter status
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Date of signing
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Enter date
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PART 2(d)
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Date of birth
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Enter date in format dd/mm/yyyy
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Usual place of residence
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Enter location
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Nationality of deceased or person lost
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Enter nationality
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Name and address of next-of-kin
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Enter name
Enter address
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Relationship of next-of-kin
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Enter relationship
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I certify that the particulars entered above are true to the best of my knowledge and belief:
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Signature of duty holder furnishing information or person acting on behalf of duty holder
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Name of duty holder/pm whose behalf information is furnished
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Enter duty holder name
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Status of signatory
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Enter status
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Date of signing
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Enter date
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NOTES
(a) To be given by geographical co-ordinates.
(b) Forename(s) in full, followed by surname, all in block capitals.
(c) To be accompanied by the certificate of a registered medical practitioner who holds a licence to practise as to the cause of death or a statement of the reason why such a certificate is not available.
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End of Part L Detailed Report
ROGI Form 1.4 - Date of Issue 03/02/2016
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