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Risk/Event Report
Originator Details
Department:
Password:
* Name:
* Email:
Distribution & Processing responsabilities (To left blank : Defined by Quality & Safety Team)
Please check if you are concerned by the processing of this report
The head of departments checked below must participate to the processing of this report -Evaluate, Investigate and define actions-
Concerned Departments::






If others, please define:
Important to remember: 
This form allows you to identify and report a Hazard/Risk that can lead to an Occurrence, Incident or Accident.
This form is for reactive and proactive reporting but is also aimed at preventing this type of occurrence from happening.
This form must be filled as soon as possible upon identification of a hazard, but within a maximum of 24 hours
(To the manager of the Safety Management System or HSE)
This form does not devolve the responsibility of an individual to take immediate action to prevent an unsafe event.
In accordance with heliconia Just Culture principile, the company will not initiate a disciplinary procedure
against a staff member who has made a safety report in good faith. This principle does not apply to
cases of deliberate violations or criminal acts.
The editor of this form can choose to be identified or remain anonymous.
EVENTS DETAILS 
Event area:





Type of Event:
:
Hour of the event:
Activity:
Phase of operation:
Reason:

If Others, please define:
ADDITIONAL INFORMATION & SUGGESTIONS
Additional Information: :
Suggestions of solutions:
Occurrence Details
Severity:
Summary:
Description:
Occurrence Date:
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Country:
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