Incident Report

• Job

• Conducted on

  Date

• Prepared by

• Location
  Address

Incident Details

• What was the Incident/Near Miss?

• Date and time of incident

  Date

• York Vehicle registration

  Media

• Vehicle Type

  Select Truck Trailer Crane Truck Bakkie Bell Tri Logger Tractor Fire Truck Car Forwarder Harvesting Machine

  • Truck
  • Trailer
  • Crane Truck
  • Bakkie
  • Bell Tri Logger
  • Tractor
  • Fire Truck
  • Car
  • Forwarder
  • Harvesting Machine

• Vehicle License Disc

  Media

• York Driver Name

• York Driver License

  Media

• York Driver ID

  Media

York Driver Statment

• Driver Statement

• Driver Signature

  Sign

• Were there any injuries?

  Yes

  No

• Description of injury

• Take photo of injury

  Media

• Was there any damage to property or plant?

  Yes

  No

• Description of damage

• Take photo of damage

• What caused the incident?

• Take photo of surrounding environment including any annotations

  Media

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

• Management comments

• Is recovery required

Sign Off

• Signed off by supervisor when corrective actions have been adopted and monitored

• Supervisor sign off

  Sign