Title Page

  • Document No.

  • Audit Title

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Personnel


  • never walk by.jpg
  • Select Hazard or Near Miss

  • Please select the type of Hazard you are reporting.

  • Use matrix to evaluate Hazard.

  • Potential Risk - Choose Extreme/High/Medium/Low

  • Site

  • Enter Date of Report

  • What department do you work ?

  • Reported By Enter Name and Sign

  • 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

  • Enter Photo if applicable

  • 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.

  • Detail what action you took to protect your workmates and/or resolve the issue.

  • What further actions do you suggest to resolve ?

Supervisor/Manager Signoff

  • Name and signature

  • Have you given feedback to initiator ?

  • Date and Time you were aware of issue

  • InControl Reference Number

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