North 3 Near Miss Report V2

• Conducted on

  Date

• Name

• Was there anyone injured in the incident?

  Yes - stop this report and call manager straight away to report accident

  No - continue

• Location - screenshot from FS App. Use section below if not on a job.

  Media

• Freetype where incident happened if not on a job.

• What Happened

• What PPE was being used at the time?

  Select Safety Boots Hard Hat Gloves Safety Goggles Ear Defence Dust Mask Knee Pads Hi viz vest

  • Safety Boots
  • Hard Hat
  • Gloves
  • Safety Goggles
  • Ear Defence
  • Dust Mask
  • Knee Pads
  • Hi viz vest

• What equipment was being used at the time of the incident?

  Select Hammer Drill Combi Ladder Single Section Ladder Double Section Ladder Triple Section Ladder CAT Ladder Microlite Laddermate Harness Rope Grab Kernmantle Rope Cows Tail Other

  • Hammer
  • Drill
  • Combi Ladder
  • Single Section Ladder
  • Double Section Ladder
  • Triple Section Ladder
  • CAT Ladder
  • Microlite
  • Laddermate
  • Harness
  • Rope Grab
  • Kernmantle Rope
  • Cows Tail
  • Other

About the Accident/Incident

• Area (if at customers property)

  Select Driveway Garden Hallway In the van Roadway Kitchen Living room Loft Stairs Pavement Other (specify in free text) Stock Location

  • Driveway
  • Garden
  • Hallway
  • In the van
  • Roadway
  • Kitchen
  • Living room
  • Loft
  • Stairs
  • Pavement
  • Other (specify in free text)
  • Stock Location

• Weather/Environment

  Select Wet Dry Icy Windy Extreme heat Extreme cold Other

  • Wet
  • Dry
  • Icy
  • Windy
  • Extreme heat
  • Extreme cold
  • Other

• If OTHER, provide details

• Add any relevant photos if applicable

  Media

Please email to your own manager and also covering manager if applicable.