Event Notification - Local

• Document No.

• Client / Site

• Prepared by

Event Type

• The Event is a:

  Select Hazard Near Miss Personal Injury Environmental Equipment Non Work Related Occupational Exposure Occupational Illness/Disease Business Process External Issue

  • Hazard
  • Near Miss
  • Personal Injury
  • Environmental
  • Equipment
  • Non Work Related
  • Occupational Exposure
  • Occupational Illness/Disease
  • Business Process
  • External Issue

Event Details

• Brief Description:

Occurred Date/Time

• Select date

  Date

Reported Date/Time

• Select date

  Date

Location

• Add location
  Address

• Details of site specific location

Detailed Description

• Draw sketch

  Drawing

Immediate Actions Taken

Objects Causing Injury

• Object Causing Injury:

  Select Animal Human Agencies Flora Drugs or Pharmaceutical Food and Drink Involved only - No Injury or Illness Biological Agencies Chemicals Gas Fire/Smoke/Heat Fragments Non Metallic Substances Non Physical Agency Radioactive Material Weapons Environment Equipment Non Powered Equipment and Tools Powered Hand Tools Non Powered Office and Household Equipment Machinery and Fixed Plant Mobile Plant Other Transport Surface Mobile Equipment Vehicle

  • Animal
  • Human Agencies
  • Flora
  • Drugs or Pharmaceutical
  • Food and Drink
  • Involved only - No Injury or Illness
  • Biological Agencies
  • Chemicals
  • Gas
  • Fire/Smoke/Heat
  • Fragments
  • Non Metallic Substances
  • Non Physical Agency
  • Radioactive Material
  • Weapons
  • Environment
  • Equipment Non Powered
  • Equipment and Tools Powered
  • Hand Tools Non Powered
  • Office and Household Equipment
  • Machinery and Fixed Plant
  • Mobile Plant
  • Other Transport
  • Surface Mobile Equipment
  • Vehicle

Mechanism of Injury

• Mechanism of Injury:

  Select Biological Factors Bite - Other Animal Bite - Snake Bite - Sting Insect Effects of Heat/Cold Effects of Wind/Weather Chemical Substance Dismounting/Climbing Down Fall from Height Trip/Slip Involved Only - No Injury or Illness Caught between Objects Hit by Falling Object Hit by Moving Object Hit Object with Body Part Slide or Cave In Confinement in Oxygen Deficient Place Drowning or Near Drowning Electricity Mechanical Vibration Pressure Variations Radiation Rubbing Sounds - Long Term Sounds - Single Sudden Mental Stress Factors Muscular Stress Repetitive Movement Other Multiple Mechanisms Vehicle Machinery Accident

  • Biological Factors
  • Bite - Other Animal
  • Bite - Snake
  • Bite - Sting Insect
  • Effects of Heat/Cold
  • Effects of Wind/Weather
  • Chemical Substance
  • Dismounting/Climbing Down
  • Fall from Height
  • Trip/Slip
  • Involved Only - No Injury or Illness
  • Caught between Objects
  • Hit by Falling Object
  • Hit by Moving Object
  • Hit Object with Body Part
  • Slide or Cave In
  • Confinement in Oxygen Deficient Place
  • Drowning or Near Drowning
  • Electricity
  • Mechanical Vibration
  • Pressure Variations
  • Radiation
  • Rubbing
  • Sounds - Long Term
  • Sounds - Single Sudden
  • Mental Stress Factors
  • Muscular Stress
  • Repetitive Movement
  • Other Multiple Mechanisms
  • Vehicle Machinery Accident

Witnesses

• Name and Contact details

Investigation Team

• Manager Name: