Title Page
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Site conducted
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Document Number
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Conducted on
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Prepared by
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Location
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Incident or Near Miss ?
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Name of person reporting incident:
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Person/s involved in incident:
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Date &Time of incident:
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Plant/Unit Number/s
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Location of incident:
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What was the task being performed at the time of the incident?
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What happened?
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Include photos where possible
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Was a Risk Assessment completed?
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Witness Statement
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Signature:
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Name of Witness:
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What factors contributed to the incident (why did it happen)?
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Environment (e.g. weather, lighting, layout)
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Equipment/materials (e.g. guarding, maintenance)
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Work systems (e.g. hazard not identified or reported then create an action)
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People (e.g. fatigue, communication)
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Corrective actions using Hierarchy of Control (what are we going to do about it)?:
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Signature
