Accident / Incident / Near Miss Report & Investigation

Accident / Incident / Near Miss Report

• Document No.

• Site Name & City/Town

• Conducted on

  Date

• Prepared by

• Add signature

  Sign
• Location
  Address

Injured Persons Details

• Name:

• Contact Number:

• Address:
  Address

• Employment Details:

  Select Employee Contractor

  • Employee
  • Contractor

• Employers Name:

• Employers Address:

Details of Incident/Injury/Near Miss

• Nature:

  Select Accident Incident Near Miss

  • Accident
  • Incident
  • Near Miss
• Location of Incident (Site, Plot No. Room Etc.):
  Address

• Date & Time of Incident:

  Date

• Brief Description of Incident:

• Date Reported to Health & Safety Manager:

  Date

Injury Details (if applicable)

• Nature of injuries (if any):

• Part/s of body injured (if applicable):

• Add drawing

  Drawing

• Treatment Recieved?

  Select 1st Aid on Site Doctor Hospital Ambulance

  • 1st Aid on Site
  • Doctor
  • Hospital
  • Ambulance

Site conditions at the time of the Incident:

• Weather etc:

Other:

• Was any machinery involved?

  Yes

  No

  N/A

• Were any photos taken?

  Yes

  No

  N/A

• Add media

  Media

What action was taken immediately after the incident?

• Enter description

Witness Statements

• Select Yes N/A

  • Yes
  • N/A

Witness 1:

• Name:

• Contact No:

• Address:
  Address

Witness 1: Describe What Happened (saw/heard before, at time of, after)

• Enter Description:

Witness 2:

• Name:

• Contact No:

• Address:
  Address

Witness 2: Describe What Happened (saw/heard before, at time of, after)

• Enter Description:

The way forward

• Can any improvements be made as a result of this incident?

  Select Yes No

  • Yes
  • No

What improvements are required?

• Details