North 3 Near Near Miss Report V1

• Conducted on

  Date

• Prepared By

PLEASE COMPLETE ALL FIELDS FULLY AND ACCURATELY

• Time and Date of Incident

  Date
• Where did this happen?
  Address

Details of Affected People

• Affected Person

  Sign

• Was the affected person injured in this Incident?

  Select Yes No

  • Yes
  • No

• Involvement

  Select Injured Person Affected Person (No Injury) Witness First on Scene Manager First Aider Security Other Involvement

  • Injured Person
  • Affected Person (No Injury)
  • Witness
  • First on Scene
  • Manager
  • First Aider
  • Security
  • Other Involvement

Injury Assessment

• Injury/Illness

  Select Yes No

  • Yes
  • No

• Severity Level

  Select No Treatment (and return to work) First Aid (and return to work) Professional Medical Treatment Required Restricted Work Absence from Work Major Injury (eg broken bones) Fatal

  • No Treatment (and return to work)
  • First Aid (and return to work)
  • Professional Medical Treatment Required
  • Restricted Work
  • Absence from Work
  • Major Injury (eg broken bones)
  • Fatal

• Part of Body

  Select Abdomen Ankle Arm Back/spine Chest Ear Elbow Eye Face Finger Foot Groin Hand Head Hip Internal Knee Leg Lung Mouth Neck Shoulder Toes Wrist N/A

  • Abdomen
  • Ankle
  • Arm
  • Back/spine
  • Chest
  • Ear
  • Elbow
  • Eye
  • Face
  • Finger
  • Foot
  • Groin
  • Hand
  • Head
  • Hip
  • Internal
  • Knee
  • Leg
  • Lung
  • Mouth
  • Neck
  • Shoulder
  • Toes
  • Wrist
  • N/A

• Side of Body

  Left

  Right

  N/A

• Injury Comments

• Area

  Select Upper Lower Inner Outer Cheek Chin Forehead Jaw Nose Thumb Index finger Middle digits Sole Big toe Little toe Back of hand Palm of hand Front Back Lips Inside mouth Teeth Unknown N/A

  • Upper
  • Lower
  • Inner
  • Outer
  • Cheek
  • Chin
  • Forehead
  • Jaw
  • Nose
  • Thumb
  • Index finger
  • Middle digits
  • Sole
  • Big toe
  • Little toe
  • Back of hand
  • Palm of hand
  • Front
  • Back
  • Lips
  • Inside mouth
  • Teeth
  • Unknown
  • N/A

Treatment Details

• Was treatment given?

  Select Yes No N/A

  • Yes
  • No
  • N/A

• When was treatment given?

  Date

• Who provided the treatment?

  Select First Aider Doctor Occ Health Nurse Bystanders Customer Line Manager Other

  • First Aider
  • Doctor
  • Occ Health Nurse
  • Bystanders
  • Customer
  • Line Manager
  • Other

• Nature of treatment:

About the Accident/Incident

• Area (if at customers property)

  Select Driveway Garden Hallway In the van Kitchen Living room Loft Pavement Roadway Stairs Other

  • Driveway
  • Garden
  • Hallway
  • In the van
  • Kitchen
  • Living room
  • Loft
  • Pavement
  • Roadway
  • Stairs
  • Other

• 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

• Give as much detail as you can about: weather or ground conditions, names of substances and equipment involved; circumstances leading up to the event, part played by all people involved and what the injured personas doing at the time of the incident.

• What were the sequence of events leading up to this incident taking place?

• What Happened

• Add any relevant photos including Job details Screen shot MANDATORY

  Media

• Where did this occur

  Home Service & Supply Location

  Overseas

  Production location

  Sky Premises

• What was the Root Cause of this incident?

  Select Manual handling Slip,trip,fall same level Animal or Insect Fall from height Use of hand tools Use of power tools Contact with electric Struck by object Step on strike against Struck by moving vehicle

  • Manual handling
  • Slip,trip,fall same level
  • Animal or Insect
  • Fall from height
  • Use of hand tools
  • Use of power tools
  • Contact with electric
  • Struck by object
  • Step on strike against
  • Struck by moving vehicle

• What was the immediate cause of this incident?

• What PPE was being used at the time?

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

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

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

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

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

Agreement

• I understand that the company will use this information to meet its Health and Safety reporting and recording legal duties and for internal management purposes

  Select Yes No

  • Yes
  • No

• Engineer Signature

  Sign