Title Page

Business name, postal address and telephone number:

  • Business Name:

  • Postal Address:

  • Telephone number

  • Conducted on

Information

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)

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

  • Time and Date:

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

7. Agency of incident &/or near miss:

9. Witness

  • Was there a witness?

  • Who?

10. Space for drawing if appropriate:

  • Drawing space

What, where & how.

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:

  • Other causes:

  • Any other comments on cause:

13. Action

  • Details
  • Detailed action to be taken

  • Timeframe

  • Who by

  • Date Completed

  • Severity

  • Chance of reoccurrence?

  • New Hazard?

Add to hazard register

  • Complete?

Sign off

  • Name:

  • Position:

  • Signature:

  • Date:

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.