Hilltop Harvesting Near Hit/Incident Report

• Date and time I'm completing this near hit or incident report

  Date

• Submitted by

  Sign

Details of near hit or incident

• Date and time

  Date

• Where did it occur?

• What task was being performed?

• What type of event was it?

  Near hit

  Minor injury - no first aid

  First aid required

  Medical treatment

What happened?

• What happened - leading up to, during, and after the event

• Had anything changed? Work method, team members, weather, site etc...

  Yes

  No

  N/A

• Give details about what had changed

• Photos of the near hit or incident

  Media

Basic causes

• Did the immediate causes involve:

  Select Equipment Materials Environment People

  • Equipment
  • Materials
  • Environment
  • People

• Give details of how environment was a factor

• Give details of how materials were a factor

• Give details of how equipment was a factor

• Give details of how people were a factor