Near Miss Incident Report Template

• Site conducted

  Select

• Document No.

• Shift

  Blue

  Orange

  Purple

  Not Applicable

• When did it happen

  Date

• Select the category the near-miss most relates to:

  Select Fall from height Slips / Trips / Fall Fall from equipment Hazardous Manual Handling Electric Shock Caught between/underneath Hazardous Substance Falling object Other

  • Fall from height
  • Slips / Trips / Fall
  • Fall from equipment
  • Hazardous Manual Handling
  • Electric Shock
  • Caught between/underneath
  • Hazardous Substance
  • Falling object
  • Other

• Category of Near Miss

  Unsafe Behaviour

  Unsafe Condition

  Unsafe Equipment

  Other

• Instructions:
  1. Required to be completed when you experience a Safety Near Miss in the workplace
  2. To be completed in full and emailed to direct manager or the Health & Safety Manager.

• A Near Miss is defined as an unplanned event that did not result in injury, illness or damage – But had the POTENTIAL TO DO SO.

Near Miss Details

• Location of Near Miss

  Select Air Lock Entry Administration / Offices Amenities Batching Flavours Batching Fruit Bin Wash Bulk Sugar Chemical Storage Cooking Dispatch Chiller Dispatch Loading Dock Dispatch Dry Goods Dry Goods Warehouse Grounds Site 1 Grounds Site 2 Hotbox Maintenance Workshop NPD Lab Pack Floor Prod Loading Dock Production Powders / Allergen Production Staging / Lift QA Lab Receivals Chiller Receivals Freezer Site 3 Tote Wash - Site 2 Waste Water Treatment

  • Air Lock Entry
  • Administration / Offices
  • Amenities
  • Batching Flavours
  • Batching Fruit
  • Bin Wash
  • Bulk Sugar
  • Chemical Storage
  • Cooking
  • Dispatch Chiller
  • Dispatch Loading Dock
  • Dispatch Dry Goods
  • Dry Goods Warehouse
  • Grounds Site 1
  • Grounds Site 2
  • Hotbox
  • Maintenance Workshop
  • NPD Lab
  • Pack Floor
  • Prod Loading Dock
  • Production Powders / Allergen
  • Production Staging / Lift
  • QA Lab
  • Receivals Chiller
  • Receivals Freezer
  • Site 3
  • Tote Wash - Site 2
  • Waste Water Treatment

• Supporting photos of near miss incident

  Media

• Describe details of the "Near Miss"

• What was immediately done about the near miss? Select from drop down. Multiple answers can be chosen

  Select Nothing Reported immediately to shift Supervisor / Manager Area isolated & quarantined Housekeeping applied to area Machinery tagged out & isolated Reported to Maintenance First Aid treatment applied Other - Describe

  • Nothing
  • Reported immediately to shift Supervisor / Manager
  • Area isolated & quarantined
  • Housekeeping applied to area
  • Machinery tagged out & isolated
  • Reported to Maintenance
  • First Aid treatment applied
  • Other - Describe

• Other - Record text

• Has an injury occurred. If yes, An incident report in Qudos must be completed

  Yes

  No

• By my signature below I attest that the information I have provided is true and accurate to the best of my knowledge:

• Signature:

  Sign

• Instructions: SUPERVISOR / MANAGER to record action taken (if any) to address reported near miss

Follow Up Action

• Is Corrective / Preventative action required?

  Yes

  No

• Record details of action taken

• Record Date Action Taken

  Date

• Record Date Near Miss Closed

  Date

• Manager / Supervisor Sign off

  Sign