Title Page
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Project Number
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Location of Near Miss/Hazard/Incident
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Site Address
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Date & Time
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Prepared By
Report Form
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Level Of Near Miss, Incident (Accident) and/or Hazard
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Ground Surface and Weather Conditions (where applicable)
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Reported By (optional)
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Description of Near Miss, Incident (Accident) and/or Hazard
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Near Miss, Incident (Accident) and/or Hazard Photo(s)
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Supervisor Review
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Actions Taken Following Supervisor Review
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Root Cause(s) – Mandatory Requirement for Red
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Were Photos Taken?
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Site Supervisor/Manager
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Date Report Sent to H&S Advisor
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Comments from H&S Advisor including any additional Further Actions
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H&S Advisor
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Position Held
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Is the incident reportable under RIDDOR 2013?
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Date Reported to HSE (when applicable)
