Injury/Accident/Incident/Near Miss Report

• Conducted on

  Date

• Prepared by

• Location
  Address

• Personnel

SECTION I

• Name/s of staff involved

• Date and time of incident

  Date

• Date and time incident was reported.

  Date

• To whom was the incident reported?

• Location of incident. (Specify site location)

• Was there any witness(es)? If yes, provide name(s).

  Yes

  No

  N/A

• Has BAE/SHEQ Manager been informed?

  Yes

  No

  N/A

DETAILS OF INJURY, IF APPLICABLE

• Describe injury/incident/near miss

• Detail any first-aid or medical treatment administered. (Provide names)

• Contact details for police (if involved)

• Did police test for alcohol/drugs

• Has Spectrum CS Accident book been completed?

  Yes

  No

  N/A

DETAILS OF DAMAGE, IF APPLICABLE

• Property Damage:

  None

  Minor

  Serious

  Major

• Photo of damage.

  Media

• Property Damage:

  N/a

  Vehicle

  Equipment

  Private Property

• Photo of damage.

  Media

• Your vehicle registration

• Detailed description of incident. (Include environmental conditions at time of incident)

• Accident/injury/near miss scene photos:

  Media

• Immediate (Direct Causes):

• Direct cause photo:

  Media

• Direct cause photo:

  Media

ANALYSIS

• Contributing (underlying) Factors:

• Contributing factors photo:

  Media

• Corrective Action (Include detail description of action and person(s) responsible for actions)

• What was the potential for severity?

  Minor

  Serious

  Major

• What could have potentially happened?

• What is the probability of reoccurrance?

  Remote

  Improbable

  Probable

• Select date

  Date

• Signature

  Sign

Third party details

• Names of third parties

• Address of third parties

• Insurance details of third parties.

• Did police test third parties for alcohol/drugs

  Yes

  No

  N/A