Information
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Document No.
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Company Name
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Address
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This form may be used by any member of staff, visitor or contractor. It should be used to bring to the attention to the company any near miss or incident arising out of work being undertaken, which could have resulted in injury. The form must NOT be used for reporting accidents where people were injured. An Accident Report Form should be used in such cases.
1. Date and time of the Incident.
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Date and time of the incident.
2. Location (please be as accurate as possible).
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Location.
3. Details of Person Reporting.
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Forename(s).
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Surname.
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Category of Person (choose 1 option).
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If Other - Give more details.
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Contractor's Name (Where applicable)?
4. Description of the Incident. Please use this section to record the near-miss or incident, or to make a comment or suggestion for improvement
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Describe what happened?
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What immediate actions were taken at the time?
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List additional actions which could be taken to prevent a similar occurrence?
5. Photograph(s) of the area and/or results of the near-miss or incident.
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Photograph of the surrounding area showing where possible the circumstances that led to the near-miss or incident. Also to show the results of the near-miss or incident.
6. Signatures
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Name and signature of person reporting the event
7. E-mail the completed form to:
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'Export' the completed form directly by e-mail to a member of the senior management team for approval
Report Approved By
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Additional actions taken:
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Name:
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Date:
