Incident Notification

• Site conducted

  Select

• Conducted on

  Date

• Reported by

• Location
  Address

• People Involved/ Company Name:

• Occupation/ Industry:

• Job/ Activity:

INCIDENT DETAILS

• Date of Near Miss/ Incident:

  Date

• Time:

  Date

• Location:

• Area:

INCIDENT CIRCUMSTANCES

• Description of Events:

• Machinery / Equipment Involved

DAMAGE DETAILS/ INJURY DETAILS

• Any persons injured, equipment, property or other damage

CORRECTIVE ACTION REQUIRED TO PREVENT SIMILAR INCIDENT

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WITNESS DETAILS

• Were there any witnesses to the near miss?

  Yes

  No

  N/A

• Have witness statements been obtained from all witnesses?

  Yes

  No

  N/A

• Please provide names & contact details from all witnesses:

REPORTED BY

• Name & Surname:

• Signature:

  Sign

• Date:

  Date