CFMHS 15b - IR2 form Rev 6.0 \Aug 18

• HS/06/04/IR2 Rev 3.0 Feb 2014

NATURE OF NEAR MISS/ POTENTIAL INCIDENT.

• BP, Booker, FSHC, HOF, Homebase or Makro

  Select BP Booker/Makro FSHC HOF Homebase/Bunnings Other (specify)

  • BP
  • Booker/Makro
  • FSHC
  • HOF
  • Homebase/Bunnings
  • Other (specify)
• Store address
  Address

• Date / Time.

  Date

• Health

• Safety

• Environment

• DESCRIPTION OF INCIDENT.

• Picture.

  Media

• ACTION TAKEN TO RESOLVE ISSUE IF AVAILABLE

• Picture.

  Media

• Job Status

  Job completed By Technician

  Job raised for Technician to complete

  Job Raised with Desk and passed out to 3rd party

  Notify Store manger

• Enter job Number raised

• Technician signature

  Sign

• Managers signature

  Sign