Title Page
-
Conducted on
-
Prepared by
Sign off
Details of the affected person
-
Person involved:
-
Details of the limited company, including whether the person is self employed (CIS or PSC) or works via an umbrella company?
-
Full Name of the Affected Person
-
Address of the Affected Person
-
Telephone Number of the Affected Person
Near miss details
-
Date and Time of near miss
-
Where did the near miss occur and, if at a customer site, what is the name of the customer?
-
Where did the near miss occur and, if at a customer site, what is the address of the customer?
-
What happened? Describe the type of work being carried out when the near miss occurred, the series of events and the nature of the injuries
-
add photo
-
Were there any witnesses to the accident/incident?
-
Name of the witness
-
Address of the witness
-
Telephone number of the witness
-
Are you providing a signed witness statement?
-
Why not?
Action
-
What external factors, if any, led to or caused the accident/incident?
-
Has action been taken to try and avoid a recurrence of the accident/incident?
Sign off
-
Person completing report
-
Signature
