Safetwise Accident / Near miss report

• Conducted on

  Date

• Prepared by

• Location
  Address

• Company Name

  Paul Gordon Contracting

  B & W Blackbee

  PJS Building

  Stone Transport and Hiab

  Heavy Equipoment Ltd

• Name of person

• Address

• Phone number

• Date of Birth

• Sex

  Male

  Female

Employment Details

• Job Title

• Employment status

  Permanent

  Casual

  Contractor

  Visitor

Accident Details

• Date and time

  Date

• Hours at work

• Date and time reported

  Date

• Accident Details

  Near Miss

  Accident Lost Time

  Accident No Lost Time

• Treatment Given

  No Treatment

  First Aid

  Doctor

  Hospital

Nature of Injury

• Where did it happen?

• How did the accident happen?

• Was the person trained for the job?

  Yes

  No

  N/A

• If a vehicle was involved record or type vehicle / rego

  Yes

  No

  N/A

• Was a significant hazard involved?

  Yes

  No

  N/A

• What was the significant hazard?

• Is the hazard on the hazard register?

  Yes

  No

  N/A

• Please write a hazard ID form

• How serious could the injuries have been?

Steps to prevent similar event happening again

• Person Responsible

• Specific Actions Requied

• By When Date

  Date

• Date Completed

  Date

Initial needs assessment (only complete if doctor visit was required)

• Initial needs

  Select Able to continue full duties Able to do light duties Unable to work Help available at home Assistance required at home Transport assistance needed

  • Able to continue full duties
  • Able to do light duties
  • Unable to work
  • Help available at home
  • Assistance required at home
  • Transport assistance needed

• Immediate supervisor

Form completed by

• Employee

• Signature

  Sign

• Date and time

  Date

• Management

• Signature

  Sign

• Date and time

  Date

• Management

• Date and time

  Date

• Signature

  Sign

• Treating doctor

• Date and time

  Date

• Signature

  Sign