Alan Taylor-Reed

Demo One DOA-19 Near Miss-Hazard-Incident Report

Demo One DOA Document

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Title Page

Project Number
Location of Near Miss/Hazard/Incident
Site Address
Date & Time
Prepared By

Report Form

Level Of Near Miss, Incident (Accident) and/or Hazard

Ground Surface and Weather Conditions (where applicable)
Reported By (optional)
Description of Near Miss, Incident (Accident) and/or Hazard
Near Miss, Incident (Accident) and/or Hazard Photo(s)

Supervisor Review
Actions Taken Following Supervisor Review
Root Cause(s) – Mandatory Requirement for Red
Were Photos Taken?
Site Supervisor/Manager
Date Report Sent to H&S Advisor

Comments from H&S Advisor including any additional Further Actions
H&S Advisor
Position Held
Is the incident reportable under RIDDOR 2013?
Date Reported to HSE (when applicable)

Alan Taylor-Reed

Demo One DOA-19 Near Miss-Hazard-Incident Report

Demo One DOA Document

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.