Newton Hazard, Near Miss, First Aid, Observation & Job Pause Reporting

• Document Number

• Conducted on

  Date

• Prepared by

• Is the event a:

• -Near Miss (An event occurred, though no one was hurt)

  Yes

  No

• -Hazard (Something with the potential to cause harm)

  Yes

  No

• -First Aid (Minor injury requiring on site first aid only with TM returning to work)

  Yes

  No

• -Observation & Job Pause (TM working unsafely and job pause carried out)

  Yes

  No

• Other

Location

• What is specific location, i.e. building and workstation?

Date & Time

• What date did you witness this event?

• What time did this occur at?

Incident/issue/observation

• Please give the details of the incident/issue/observation?

• What actions were taken to protect the TMs to make the area safe?

• Have you taken effective action to address this issue?

  Yes

  No

• Please provide clarification if the answer was NO.

Supervisor

• Has this been reported to area supervisor?

  Yes

  No

• Please provide clarification if the answer was NO.

• State the name of the Team Lead/Supervisor/Manager who has been made aware of the issue/incident/observation. Use N/A if the incident does not need to be reported.