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

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