Information
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Incident Report No. (001 if your first report of the day)
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Conducted on
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Employee Name (optional):
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Type of Incident (Safety Observation / Near Miss)
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Department
- Warehouse
- Production
- Logistics
- Office Area
- Yard / Car park
- Off site
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Instructions:
1. Required to be completed when you see a Safety Observation or experience a Safety Near Miss in the workplace
2. To be completed in full and emailed to your line manager or the Head of Operations. -
Near Miss Defined - A near miss as an “unplanned event that did not result in injury, illness or damage – but had the potential to do so.”
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Safety Observation Defined - Safety concerns refer to any observed hazards or potential risks in the workplace that could cause significant harm to the company’s employees, stakeholders, and property.
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Date & Time of Observation / Near Miss:
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Location of Safety Observation / Near Miss.
- Warehouse
- Production
- Logistics
- Office Area
- Yard / Car park
- Off site
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Select the category the Observation / Near Miss most relates to:
- Blocked access route
- Slip / Trip / Fall on same level
- Using Hand Tools / Equipment
- Manual Handling
- Electric Shock
- Caught between/underneath
- FLT/PPT/MHE
- Falling object
- Other (Please Specify)
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Describe the observation / How the Near Miss occurred (include the body part and type of pain):
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Describe the Observation / What lead up to and caused the Near Miss. Identify root causes:
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Photo/s that can help explain the what, where, why, or the possible injury:
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Name and Signature (optional)
Approval
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Date and time of approval
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Approver's signature
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Added to H&S data set.
