Incident/Near Miss Report

• Document Number (yyyy.mm.dd - ***)

• For example: 2023.10.10 - 001

• Job Name & Number

• Conducted on

  Date

• Prepared By

• Location
  Address

• NOTE: The TKL Group is dedicated to providing a safe and injury free workplace. All accidents or near misses shall be reported and investigated to determine the root causes. Corrective actions, measures and procedures may be implemented to prevent a reoccurrence.

Incident Details

• Enter job description

• Date and time of incident

  Date

• What was the Incident/ Near Miss?

• Were there any injuries?

  Yes

  No

• Was an Accident Report form completed? (If not, why not?)

  Yes

  No

• Was there any damage to property or equipment

  Yes

  No

• Description of damage

• Take photo of damage

  Media

• What do you think caused the incident/accident/near miss?

• Take photo of surrounding environment including any annotations

  Media

• What actions will be taken to eliminate future repeats of the incident?

Signature

• Signature of Prepared By:

  Sign

Sign Off

• To be signed off by Site Manager or Supervisor when corrective actions have been adopted and monitored

• Site Manager or Supervisor sign off

  Sign