Incident/Accident/Near Miss Details

• Incident / Accident / Near Miss Report

• Location

• Report Initiation Date

  Date

1. Incident/Accident/Near Miss Details:

• Date & Time of Incident / Accident / Near Miss

  Date

• Employee Name

• Report Completed By

• Client

• Location of Incident / Accident / Near Miss
  Address

• Description of Incident/Accident/Near Miss:

• Add photos if possible

  Media

2. Classification of Loss:

• Type of Incident

  Select Near Miss Incident Incident Avoidable Vehicle Incident (PVI) Non Avoidable Vehicle Incident (NPVI) Dangerouse Occurrence Incident Serious Incident Serious Vehicle Incident

  • Near Miss Incident
  • Incident
  • Avoidable Vehicle Incident (PVI)
  • Non Avoidable Vehicle Incident (NPVI)
  • Dangerouse Occurrence Incident
  • Serious Incident
  • Serious Vehicle Incident

• Check Classification of Loss (choose all that apply)

  Select Personal Injury Occupational Injury Chemical Exposure Equipment Failure Equipment Damage Property Damage Enviromental Spill Explosion/Fire Other

  • Personal Injury
  • Occupational Injury
  • Chemical Exposure
  • Equipment Failure
  • Equipment Damage
  • Property Damage
  • Enviromental Spill
  • Explosion/Fire
  • Other

• If other please describe

3. Severity of Incident or Accident:

• Choose Appropriate Level Of Severity for Each Category

• Health or Safety

  No Injury

  First Aid Only

  Minor Injury, Medical Treatment, Restricted Work, Lost Time Injury

  Serious Injury, Localised Evacuation

  Mutiple Serious Injuries, Fatality, Major Evacuation

• Environmental Impact

  Minimal Cleanup

  Small Cleanup

  Cleanup Requires

  No Impact

4. Severity of Property Damage of Equipment Loss

• Chose Level Of Severity

  Zero

  Between $0.00 - $5,000

  Between $5,000 - $25,000

  Over $25,000

5. Type of Property Loss

• Check Type of Property Loss (check all that apply)

  Select Building Equipment Vehicle(s) Tools Materials Various Processes Other

  • Building
  • Equipment
  • Vehicle(s)
  • Tools
  • Materials
  • Various Processes
  • Other

• If other please describe

6. Direct Causes:

• What failures to act or conditions caused the event

• Substandard Actions (check all that apply)

  Select Operating without authority Failure to follow policies & procedures Failure to use PPE Behaviour - horseplay/misconduct Improper position for task improper lifting Using defective equipment servicing equipment in motion Improper material handling - loading/placement Making safety device inoperative Operating at improper speed Under influence or impaired - substances/fatigue

  • Operating without authority
  • Failure to follow policies & procedures
  • Failure to use PPE
  • Behaviour - horseplay/misconduct
  • Improper position for task
  • improper lifting
  • Using defective equipment
  • servicing equipment in motion
  • Improper material handling - loading/placement
  • Making safety device inoperative
  • Operating at improper speed
  • Under influence or impaired - substances/fatigue

• Substandard Conditions (check all that apply)

  Select Defective tools/equipment/materials Inadequate guards/barriers Congestion / restricted work area Inadequate warning syatem Poor Housekeeping Poor ergonomics, set-up or design Fire / Explosion hazard Inadequate ilumination Hazardous environmental conditions - gasses/dust/smoke/fumes/vapors Inadequate/Improper PPE Extreme tempuratures

  • Defective tools/equipment/materials
  • Inadequate guards/barriers
  • Congestion / restricted work area
  • Inadequate warning syatem
  • Poor Housekeeping
  • Poor ergonomics, set-up or design
  • Fire / Explosion hazard
  • Inadequate ilumination
  • Hazardous environmental conditions - gasses/dust/smoke/fumes/vapors
  • Inadequate/Improper PPE
  • Extreme tempuratures

7. Root Causes

• What are the reasons for the actions or conditions

• Personal factors (check all that apply)

  Select Inadequate physical capability Ineadequate mental capability Stress: Physical demands Stress: Mental demands Lack of knowledge Lack of skill/experience Lack of communication/infomation Failure to address/recognize hazard Ineadequate inspection of tools/equipment Inadequate motivation - Did not move/obtain correct tool/did not check

  • Inadequate physical capability
  • Ineadequate mental capability
  • Stress: Physical demands
  • Stress: Mental demands
  • Lack of knowledge
  • Lack of skill/experience
  • Lack of communication/infomation
  • Failure to address/recognize hazard
  • Ineadequate inspection of tools/equipment
  • Inadequate motivation - Did not move/obtain correct tool/did not check

• Job Factors (check all that apply)

  Select Inadequate instruction/training Inadequate/lack of supervision Inadequate engineering Inadequate purchasing Inadequate maitnence Inadequate tools/equipment Inadequate work procedures Inadequate work conditions Wear/tear Previous hazardous situations addressed not corrected Abuse/misuse Lack of enforcement of policies and procedures

  • Inadequate instruction/training
  • Inadequate/lack of supervision
  • Inadequate engineering
  • Inadequate purchasing
  • Inadequate maitnence
  • Inadequate tools/equipment
  • Inadequate work procedures
  • Inadequate work conditions
  • Wear/tear
  • Previous hazardous situations addressed not corrected
  • Abuse/misuse
  • Lack of enforcement of policies and procedures

• Description of direct and root causes - actions and conditions

8. Corrective Actions

• Describe actions taken to prevent the re-occurrence.

• Describe follow up that will be done to prevent re-occurrence.

• List dates for implantation of corrective actions.

Report Stages

• Initial Report Date

  Date

• Final Reporting Date

  Date

• Manager Name

• Manager Signature

  Sign

• Date Signed

  Date

• Date reviewed in safety meeting

  Date