Craig Brown

CMS - H&S - Near Miss, Incident, Hazard Report Form

Near Miss, Incident, Hazard Report Form

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Use this Template

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Title Page

Document No. CMS HS 21-01
NEAR MISS / INCIDENT / HAZARD REPORT FORM (PLEASE ENTER BELOW)
CONTRACT
CONTRACT No.
DATE AND TIME OF INCIDENT
LOCATION OF INCIDENT
PLANT / EQUIPMENT / PERSONNEL INVOLVED
TIME REPORTED
REPORTED BY

DETAILS OF INCIDENT

Evidence Photograph/s

RECOMMENDATIONS AND REMEDIAL ACTION

CONFIRMATION OF IMPLEMENTATION OF REMEDIAL ACTION
NAME OF PERSON REPORTING
DATE:
JOB TITLE
DEPT.

Craig Brown

CMS - H&S - Near Miss, Incident, Hazard Report Form

Near Miss, Incident, Hazard Report Form

Use this Template

Print as PDF

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.