Title Page
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Conducted on
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Prepared by
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Location
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Site ST No.
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Client
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Site Supervisors name
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Person filling out the reports name:
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Type of incident
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Add details of near miss
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Add picture or area
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Is there further actions required to make it safe?
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Enter what needs to be done and by whom?
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How has the area been left safe?
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Add picture to show area is now safe
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Describe the incident
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Add a photo of the incident close up
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Add a photo of the area from a distance
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Add any further pictures of any damage caused
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Who was involved in the incident?
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Was there any witnesses?
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As the supervisor did you check the area prior to works that morning as part of the daily briefings
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Did you foresee any areas of concern?
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Did you put in place controls measures for the areas of concern?
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Where these controls communicated to the operatives carrying out the works?
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What where the additional controls and how where they communicated to those involved?
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Why where additional controls not communicated to those involved?
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Why did you not see foresee there being an issue with the works as they were planned?
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Why was the area not checked prior to works being started?
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Was the works the same as described within the RAMS?
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Was this caused by a foreseeable risk?
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Explain how it was not a known risk for the activity being undertook.
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Why where the controls for the foreseeable risk not adequate to prevent this incident from occurring?
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Why where the works allowed to continue without sufficient RAMS in place?
