Title Page
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Document No.
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Audit Title
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Client / Site
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Conducted on
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Prepared by
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Location
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Personnel
Details
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Select Hazard or Near Miss
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Please select the type of Hazard you are reporting.
- Biological
- Chemical
- Electrical (or Energy)
- Fatigue
- Fire or Explosion
- Fixed Plant & Equipment
- LOTO
- Manual Handling
- Mobile Plant & Equipment
- Noise
- Psychological
- Security
- Slip,Trip or Fall
- Temperature
- Traffic Management
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Use matrix to evaluate Hazard.
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Potential Risk - Choose Extreme/High/Medium/Low
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Site
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Enter Date of Report
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What department do you work ?
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Reported By Enter Name and Sign
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Who have you reported this to immediately ? Eg. Supervisor name, manager name. Noone for minor items.
Description: Ensure photo and comments cover What/When/Where/How
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Enter Photo if applicable
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Enter the following details: What occurred ? When did it happen ? Where exactly is it ? How did it occur, How did it affect us ?
Immediate Actions Taken.
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Detail what action you took to protect your workmates and/or resolve the issue.
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What further actions do you suggest to resolve ?
Supervisor/Manager Signoff
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Name and signature
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Have you given feedback to initiator ?
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Date and Time you were aware of issue
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InControl Reference Number
