Information
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Client / Company Name
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Address
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Conducted on
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Prepared by
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Site contacts - Name, Position & Contact details (If Possible)
Details Of Involved Parties
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Name of Worker(s) involved:
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Position of worker:
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Date & time of notification of Accident/ Incident or Near Miss
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Name(s) of any witnesses (If any):
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Contact details or position of witnesses:
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Details of injury / Injuries sustained (If any)
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Was first aid required? (If yes please list)
Location & Details Of Accident / Incident or Near Miss
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Area / Location onsite Accident / Incident or Near Miss occoured (Please list below)
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What occurred:
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Date & Time the above took place?
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Describe what happened? (Be descriptive include sequences of events, Activates being undertaken, Times etc)
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Add Photo's where possible
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Was an Accident/Injury/Near miss form filled out by client? (Request a copy if possible)
Contributing Factors & Recommendations
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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.
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Recommendations: (Please list any recommendations that you think will help remove / eliminate / isolate or reduce future reoccurrence’s of this Accident / Incident / Near Miss:
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Extra documentation to support this report:
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Client Signature
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Zoom Recruitment Rep Signature
