Incident / Injury / Near Miss Report & Investigation Form

• Document No.

• Audit Title

• Conducted on

  Date

• Prepared by

• Incident Classification

  Near Miss

  First Aid

  Medical Only (Recordable)

  Lost Time (Recordable)

Injured Persons Details

• Name:

• Contact Number:

• Address:
  Address

• Cause of Incident:

  Select Equipment Material People

  • Equipment
  • Material
  • People

Details of Incident/Injury/Near Miss

• Nature:

  Select Incident Injury Near Miss

  • Incident
  • Injury
  • Near Miss

• Date & Time of Incident:

  Date

• Task Performed when Incident Occurred

  Select FICEP Welding Grinding Material Handling

  • FICEP
  • Welding
  • Grinding
  • Material Handling

• Date Reported:

  Date

• Reported To:

• Title:

• Contact No:

Names of any Witnesses

• Name:

• Contact No:

• Address:
  Address

Describe What Happened

• Enter description

Injury Details (if applicable)

• Nature of injuries (if any):

• Part/s of body injured (if applicable):

• Treatment Recieved?

  Select 1st Aid Doctor Hospital Ambulance

  • 1st Aid
  • Doctor
  • Hospital
  • Ambulance

• Photo (s)

  Media

Other:

• Was any machinery involved?

  Yes

  No

  N/A

What action was taken immediately after the incident?

• Enter description

Can any improvements be made as a result of this occurrence?

• Details

• Photo (s)

  Media