OF0023 – Incident and Near Miss Reporting form

OF0023 – Incident and Near Miss Reporting form

Amendment Record

Instructions

Details of the Incident/Near miss

Table of Contents

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Unique ID

The person reporting is to follow the Incident and Accident Procedure. Identify the WHO, WHERE, WHEN, WHAT, WHY and HOW questions with regard to the incident. Complete this report and provide it to the site manager as soon as practicable.

Person Reporting Incident

First Last

Reporter Email

Reporter Phone

Short Description of Incident

Date of incident

Time of incident

Location of Incident

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Job or work order number associated

Name of Person/s Injured?

Injuries Sustained

Witnesses and Contact details

Full Description of Incident

Describe what happened including the sequence of events, investigate scene of incident or near miss; conditions present at time of incident; what was involved, what activity (if any) was taking place at the time of incident. What hazards was the worker exposed to? What may have contributed to the incident occurring?

File

Max. file size: 100 MB.

File

Max. file size: 100 MB.

File

Max. file size: 100 MB.

File

Max. file size: 100 MB.

Recommendations

Outline recommended corrective action/s (i.e. solution/s) to prevent the recurrence of the incident eg. Engineering solution? Substitution? Safe Work Procedures etc.

Signature

Section#

Para.#

Description of Change

Prepared By

Approved By

Issue#: 1 Issue Date: 13/7/2022

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