HB Incident Report - near miss

• Prepared by

SECTION I

• Date and time of incident

  Date

• To whom was the incident reported?

• Location of incident. (Specify site location)

• Foremans Name

PERSON(S) INVOLOVED

• Name/s:

• Were there any witnesses - add names and contact phone numbers

NATURE OF INCIDENT

• Detailed description of incident. (Include environmental conditions at time of incident)

• Immediate (Direct Causes):

• Contributing (underlying) Factors:

• What could have potentially happened?

• What was the potential for severity?

  Minor

  Serious

  Major

• What is the probability of reoccurrance?

  Remote

  Improbable

  Probable

• Corrective Action (Include detail description of action and person(s) responsible for actions)

• What was damaged?

• Photo of damage.

  Media

• Equipment or Vehicle Type:

• Registration # if applicable:

• Equipment ID:

• Select date

  Date

• Signature

  Sign