Record of Incident &/or Near Miss

Business name, postal address and telephone number:

• Business Name:

• Postal Address:

• Telephone number

• Conducted on

  Date

2. Location of place of work:

3. Personal data of person:

• Name

4. Occupation or job title or person involved:

5. Period of employment:

• (Employees only)

  Select 1st Week 1st month 1-6 months 6 months - 1yr 1-2 years > 2-5 years Over 5 years non-employee

  • 1st Week
  • 1st month
  • 1-6 months
  • 6 months - 1yr
  • 1-2 years
  • > 2-5 years
  • Over 5 years
  • non-employee

6. Time and date of incident &/or near miss:

• Time and Date:

  Date

• Hours worked since arrival at work (employees and self-employed only)

7. Agency of incident &/or near miss:

• Select machinery or (mainly) fixed plant mobile plant or transport powered equipment, tool or appliacne non-powered handtool, appliance, or equipment chemical or chemical product material substance environmental exposure (e.g. duct, gas) animal, human or biological agency bacteria or virus

  • machinery or (mainly) fixed plant
  • mobile plant or transport
  • powered equipment, tool or appliacne
  • non-powered handtool, appliance, or equipment
  • chemical or chemical product
  • material substance
  • environmental exposure (e.g. duct, gas)
  • animal, human or biological agency
  • bacteria or virus

9. Witness

• Was there a witness?

  Yes

  No

• Who?

10. Space for drawing if appropriate:

• Drawing space

  Drawing

11. What, where & how did the incident happen?

• Location

• Machine type:

• Fleet number:

• Task being performed:

• What was the incident, and how did the incident happen:

12. In your opinion, what was the cause of the accident?

• Choose as many that you think apply:

  Select Lack of Training Lack of Experience Lack of supervision Lack of Communication Lack of Resources / Equipment Wrong Equipment for Job Machinery Failure Inattention Poor Planning / Job Layout Not following Procedures Poor / No Procedures Fatigue Other:

  • Lack of Training
  • Lack of Experience
  • Lack of supervision
  • Lack of Communication
  • Lack of Resources / Equipment
  • Wrong Equipment for Job
  • Machinery Failure
  • Inattention
  • Poor Planning / Job Layout
  • Not following Procedures
  • Poor / No Procedures
  • Fatigue
  • Other:

• Other causes:

• Any other comments on cause:

13. Action

• Select Training Hazard Procedures PPE Requirements Health Monitoring Supervision Hazard Identification Emergency Procedures Others as described Safety Documentation / Rules New Requirements Professional Advice

  • Training
  • Hazard Procedures
  • PPE Requirements
  • Health Monitoring
  • Supervision
  • Hazard Identification
  • Emergency Procedures
  • Others as described
  • Safety Documentation / Rules
  • New Requirements
  • Professional Advice
Details

• Detailed action to be taken

• Timeframe

• Who by

• Date Completed

  Date

• Severity

  Minor

  Moderate

  Extreme

• Chance of reoccurrence?

  Rare

  Often

• New Hazard?

  Yes

  No

Add to hazard register

• Complete?

• Name:

• Position:

• Signature:

  Sign

• Date:

  Date