Incident- Accident -Near Miss Report

• Document Number

• Job

• Conducted on

  Date

• Prepared by

• Location
  Address

• NOTE: The Boring Company is dedicated to providing a safe and injury free workplace. All accidents or near misses shall be reported and investigated to determine the root causes. Corrective actions, measures and procedures may be implemented to prevent a reoccurrence.

Incident Details

• Enter job description

• Date and time of incident

  Date

• What was the Incident/ Near Miss?

• Were there any injuries?

  Yes

  No

• Description of injury

• Take photo of injury

  Media

• Was there any damage to property or equipment

  Yes

  No

• Description of damage

• Take photo of damage

  Media

• What do you think caused the incident/accident/near miss?

• Take photo of surrounding environment including any annotations

  Media

• What actions will be taken to eliminate future repeats of the incident?

• Do you commit to the TBC Safety Culture?

  Yes

  No

Signature

• Signature of Prepared By:

  Sign

Sign Off

• To be signed off by supervisor when corrective actions have been adopted and monitored

• Supervisor sign off

  Sign