The Occupational Health and Safety Incident Report shall be used to report near miss events, observations or deviations possibly affecting the Telia Company.

Items marked with a red diamond ♦ are mandatory fields.

Your Information (You, the person completing the form)

Your Name & Contact Information	♦ First Name ♦ Last Name ♦ Relationship to the Company (Select One) ♦ “Other” Relationship ♦ Employee ID Your unique ID within the Company ♦ Company Name Job Title Phone Number Include the country prefix, area code, and/or extension if applicable. ♦ E-Mail Address Username@domain.com Best Time to Contact Preferred Method of Contact

Involved parties

Person Involved	♦ Was the involved person an employee of Telia Company? Yes No Involving both employee(s) and external(s) (Select One)

Name & Contact Information	♦ First Name ♦ Last Name ♦ Relationship to the Company (Select One) ♦ “Other” Relationship ♦ Employee ID Your unique ID within the Company ♦ Company Name Job Title Phone Number Include the country prefix, area code, and/or extension if applicable. E-Mail Address Username@domain.com Best Time to Contact Preferred Method of Contact

Location

	* You may also take a snapshot or screenshot of your GPS coordinates on your mobile device and upload that when you have finished the form.

Incident Selection

Incident Details

Date	♦ Approximate Date of Event (if unknown, select today’s date) (Format: mm/dd/yyyy)

Details	♦ Please provide any details that you feel may be relevant to this event. This should include the date and time of the event (if known), how it was discovered, how the event occurred, information involved/affected, evidentiary value and any other pertinent details.

Documentation	♦ Do you have any documents to attach to this case in regard to this event? Yes No (Select One) Attention: Upon completion of this report you will be provided with a report key and password. With this information, you will be able to log back into your report and add any applicable documentation.

Other Involved Parties (Including but not limited to “Suspects”, “Accomplices”, and/or “Witnesses”)

Other Involved Parties	♦ Were any "other parties" involved in this event? Yes No Unknown (Select One)

Authorities

Authorities	♦ Are any outside authorities involved in this event? Yes No Unknown (Select One)

Password & Submit

Password	♦ Password ♦ Re-Enter Password (Passwords must be at least four(4) characters in length.)

Submit	When you submit this report, you will be issued a Report Key. Please write this information down along with your password, in a secure and private place. Neither your report key, nor your password, can be recovered, or reset once this report has been submitted. Using your Report Key and Password you can "Follow-Up" on this report by logging into teliacompany.ethicspoint.com. Follow-Up will allow you to: Upload/Attach documents to this report Respond to follow-up questions Provide additional information

Submit

When you submit this report, you will be issued a Report Key. Please write this information down along with your password, in a secure and private place. Neither your report key, nor your password, can be recovered, or reset once this report has been submitted.

Using your Report Key and Password you can "Follow-Up" on this report by logging into teliacompany.ethicspoint.com.

Follow-Up will allow you to:

Upload/Attach documents to this report
Respond to follow-up questions
Provide additional information

	If you would like to print the report, please select the PRINT button below prior to submitting this case.

Occupational Health and Safety Incident Report

near miss events, observations or deviations