Title Page
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Incident Type (pick one)
- Near Miss / Fear for safety/ Witness to an event
- First Aid (no lost time)
- Medical Treatment (lost time)
- Serious Harm
- Fatality
- Vehicle/ Equipment Damage
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Injury sustained / Damage to own vehicle or Injury to others / Damage to other vehicle/s (be specific or mark N/A)
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Date of incident
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Prepared by
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Location
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What happened? Were there any contributing factors? Was anyone else involved?
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Take photo of surrounding environment including any annotations
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What actions will be taken to eliminate future repeats of the incident?
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Who will take these actions ?
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When will the action be due?
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Other comments
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People leaders sign off that all actions have been completed
