Information
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Document No.
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Incident Location
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Conducted on
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Prepared by (witness of near miss)
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Signature
1. WHAT HAPPENED ?
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Detailed description of incident (consider the activity, what happened and why)
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Provide more details if necessary:
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Add/take picture of incident for record
2. INCIDENT INFORMATION
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ACTIVITY - What was the activity at the time of the incident ?
- Admin General
- Assisting student
- Chemicals/poisons
- Computer Work
- Curriculum Prac
- CurriculumTheory
- Equipment Usage
- First Aid
- Lesson Prep/ Clean up
- Manual handling
- Maintenance
- Meeting
- Movement around school
- Non-school activity
- Restraining Student
- School Activity
- Unauthorized Activity
- Work General
- Other: (e.g bullying)
3. HAZARD INFORMATION
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Contributing Hazard Category (please select)
- Animal/insect
- Blood/body substance
- Building fixtures
- Electricity/Gas
- Electrical appliance
- Environmental factors
- Equipment (eg.Playground)
- Fire/explosion
- Floor/ground
- Foreign object (eg. splinter)
- Furnitue
- Machinery (fixed)
- Machinery (mobile)
- Non powered tool
- Person/people
- Stairs/steps
- Stress/trauma
- Sunburn/UV radiation
- Temperature
- Travel
- Radiation/arc flash
- Virus/disease
- Water/pool
- Working/learning environment
- other
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Who identified the hazard?
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The potential for serious injury was:
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Please take a photo if necessary:
FURTHER ACTIONS
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1. Update team of Near Miss and suggested actions 2. Update any corresponding SOP's/ risk assessments, inductions, etc. 3. Record in safety register.
