Title Page
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Site conducted
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Conducted on
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Person Completing Form
Details
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Near Miss Incident: A near miss incident is an event that has occurred that had potential to cause harm but thankfully did not (Example: a fixture in reserves falls from height, narrowly missing a team member)
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What device are you using to complete this
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What device
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Has there been a near miss incident?
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Date & Time of Incident
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Person Type Involved
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Person Name Involved
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Location (drop down selection of one of following)
- Car Park
- Cleaners Storage Area
- Despatch
- Entrance / Exit
- Escalator
- Fitting Room
- Lay-By
- Lift - Goods
- Lift - Passenger
- Office
- Other
- Pallet Racking
- Plant Room
- Processing
- Receiving
- Loading Bay
- Registers
- Reserves
- Sales Floor
- Sorter
- Stairs
- Toilet / Change Room
- Decant
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Please specify
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Description of Incident
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Risk level
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If unsure of risk level, refer to risk matix
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Attachments (e.g. photos, diagram, witness report)
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Mechanism / Cause
- Being hit by moving objects
- Biological factors
- Chemicals and other substances
- Cut / Lacerations
- Falls, trips and slips of a person
- Heat, electricity and other environmental factors
- Hitting objects with a part of the body
- Manual Handling
- Other (Specify)
- Vehicle incidents
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Equipment involved (drop down selection of one of following)
- Animal, Insect or Spider
- Apparel Rail
- Asbestos
- Bale press
- Biological / Chemical
- Broken glass
- Cartons and boxes
- Clothing and footwear
- Compactor
- Dock leveller
- Electrical installation, wiring, switchboard
- Escalators, travelators
- Fixtures and fittings
- Fixture and Fittings - Apparel Arm
- Fixture and Fittings - Display Peg
- Fixture and Fittings - Module
- Forklift
- Knives or cutting instruments
- Ladders
- Lift (passenger and goods)
- Other
- Pallet jack
- Pallet wrapper
- Pallets
- People
- Registers
- Ride-on sweeper
- Safety step
- Storage equipment (eg shelving and racking)
- Silver cage
- Unspecified
- Vehicle - Car
- Vehicle - Truck
- Walkie stacker
- Waste bins
- Weather
- Wet surface
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Contributing factor/s
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Immediate corrective action/s taken
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Is further corrective action/s required
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Thank you for capturing this incident
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Add action/s by clicking "Action" above and click checkbox when done
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