Title Page
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Incident / Accident Observation No.
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Observation Date
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Observed By
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Incident Type
- (1) Near Miss or Potential Hazard
- (2) Unsafe Situation or Act
- (3) First Aid Required and/or Damage or Loss to Property
- (4) Injury Requiring visit A&E or Hospital Stay
- (5) Catastrophic or Multiple Injury(ies)
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If injury or loss occurred, please complete the following sections and enter a root cause for the incident or accident.
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Description of the Incident or Accident
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Location of Incident or Accident
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Have you completed an Accident Report
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Please enter Accident Investigation Report No.
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If you have completed an accident report then please enter the report no. below.
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If an accident report has not been completed then please complete it and change this answer to yes and enter the accident report number.
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Have you completed a Root Cause Analysis Report?
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Please enter Root Cause Analysis Report No.
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If you have completed a root cause analysis for the incident or accident then please enter the report no. and the root cause below.
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If you have not completed a root cause analysis for the incident or accident then please complete one and return to this section, change this answer and enter the relevant information.
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What was the root cause of the accident?
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Description of Near Miss or Unsafe Situation or Act
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Where possible please include photos of incident.
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Location of Near Miss or Unsafe Situation or Act
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Corrective action(s) applied
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Who is the corrective action assigned to?
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Contractor Name
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Corrective action status
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Please briefly describe the corrective action
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If the corrective action included training please enter the training record document no. here.
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Who is the corrective action assigned to?
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Corrective action status
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When was the Training completed?
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Please enter Training Record Document No. when training is complete.
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Who is the corrective action assigned to?
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Corrective action status
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When was the written warning issued?
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Please enter Written Warning Document No.
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Who was the corrective action assigned to?
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Corrective action status
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When was the stand down notice issued?
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Please enter Operative Stand Down Document No.
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Completion Date
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Completion Signature
Document Audit
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Document checked by
