Workplace Health and Safety Concern

Section A — Your contact details

1. Your name or authorised service identity (required)

2. Your relationship to the concern

3. Safe email or contact route (required)

4. Alternative contact route

5. May HSE contact you for further information?

6. Accessibility or communication requirements

7. Is there a reason your identity or contact details require additional confidentiality controls?

8. If yes, briefly explain the required control without adding unnecessary sensitive information

Section B — Previous contact

9. Have you reported this issue to HSE before?

10. If yes, previous HSE reference

11. Have you raised the issue with the organisation responsible?

12. If yes, what response or action has occurred?

13. Has another regulator, department, operational service or platform authority already been contacted?

14. If yes, organisation and reference

Section C — Organisation and activity

15. Name of the organisation, service, public body, department, local authority or other body controlling the work/activity — required if known

16. Team, unit, location or operating area — if known

17. Person in charge or responsible manager — if known

18. Type of work, duty or activity (required)

19. Where is the activity taking place?

20. If a specific Roblox experience, Discord space, premises or location is relevant, identify it sufficiently for HSE to locate the activity

21. Relevant date or period when the activity occurred or is expected to occur

Section D — The health-and-safety concern

22. What is the concern? (required)

23. What harm could occur? (required)

24. Who may be at risk? (required)

25. How many people may be affected, if known?

26. Is there a risk of serious injury, serious ill-health or another serious safety consequence?

27. Is the risk immediate or currently continuing?

28. How long has the issue existed, if known?

29. How long is it expected to continue, if known?

30. What controls are currently in place, if any?

31. Why do you believe those controls may be inadequate?

Section E — Incident or near miss

32. Has an incident or near miss already occurred?

33. If yes, date/time

34. Brief factual description of what happened

35. Was anyone injured, made unwell or otherwise harmed?

36. What immediate action was taken?

37. Existing incident, duty, risk-assessment or other internal reference, if known

Section F — Evidence

38. Do you have evidence that may help HSE assess the concern?

40. Briefly explain what the evidence shows

41. Can you provide the evidence through the authorised secure route if HSE requests it?

Section G — What action you are seeking

42. What would you like HSE to do?

43. Is there a specific safety outcome you believe is needed?

Section H — Safeguarding and other urgent concerns

44. Does this report also contain an immediate safeguarding, suicide/self-harm, criminal, public-order or other urgent non-HSE concern?

45. If yes, has the competent urgent route been contacted?

Section I — Declaration

46. Accuracy declaration (required)

I confirm that the information provided is accurate to the best of my knowledge and that I have distinguished what I observed from what another person told me.

47. Contact and responsible-organisation declaration (required)

I understand that HSE may need to contact me for clarification and may need to tell the responsible organisation what safety issue has been raised.

48. Confidentiality declaration (required)

I understand that HSE will not disclose my personal contact details to the responsible organisation merely because a concern has been reported, but the circumstances may allow the organisation to infer who reported it.

49. Name of person submitting (required)

50. Date submitted (required)

Services and information

Government activity