• Client / Company Name

  • Address

  • Conducted on

  • Prepared by

  • Site contacts - Name, Position & Contact details (If Possible)

Details Of Involved Parties

  • Name of Worker(s) involved:

  • Position of worker:

  • Date & time of notification of Accident/ Incident or Near Miss

  • Name(s) of any witnesses (If any):

  • Contact details or position of witnesses:

  • Details of injury / Injuries sustained (If any)

  • Was first aid required? (If yes please list)

Location & Details Of Accident / Incident or Near Miss

  • Area / Location onsite Accident / Incident or Near Miss occoured (Please list below)

  • What occurred:

  • Date & Time the above took place?

  • Describe what happened? (Be descriptive include sequences of events, Activates being undertaken, Times etc)

  • Add Photo's where possible

  • Was an Accident/Injury/Near miss form filled out by client? (Request a copy if possible)

Contributing Factors & Recommendations

  • Contributing Factors: (Please list all factors inc: Environment / Machinery-Equipment / Materials / Information / People that you observe or think may have contributed to this Accident / Incident / Near Miss.

  • Recommendations: (Please list any recommendations that you think will help remove / eliminate / isolate or reduce future reoccurrence’s of this Accident / Incident / Near Miss:

  • Extra documentation to support this report:

  • Client Signature

  • Zoom Recruitment Rep Signature

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.