GRISTWOOD AND TOMS version2.0 NEAR MISS REPORTING FORM - duplicate

• Document No.

• Document title

• Client / Site

• Conducted on

  Date

• Personnel on site

• Depot

  Select Croydon Shenley Richmond Ealing Portsmouth Birmingham Hastings Bexley

  • Croydon
  • Shenley
  • Richmond
  • Ealing
  • Portsmouth
  • Birmingham
  • Hastings
  • Bexley

• NAME OF PERSON WHO HAD THE NEAR MISS

• NAME OF PERSON REPORTING THE NEAR MISS (if you did not have the near miss)

• NEAR MISS DETAILS

Type of near miss. Tick as many as appropriate.

• Slips, trips and falls (ground level)

• Fall from height

• Chainsaw related

• Stump grinder related

• Underground service related

• Equipment malfunction
• Location
  Address

• DESCRIBE WHAT HAPPENED (include pictures in the box below if possible)

• Picture of near miss

  Media

• WHAT WAS THE POTENTIAL INJURY.

• COULD THIS HAVE BEEN AVOIDED.

  Yes

  No

  N/A

• Could any of the following have helped to a avoid this near miss? Tick as many as appropriate.

• PPE

• Training

• Toolbox talk

• In your opinion, could Gristwood And Toms have done anything to prevent this near miss? If yes, please give details.

  Yes

  No

  N/A

• Name

  Sign

• NOW SEND THIS FORM TO YOUR MANAGER.