Significant Near Miss Report

• Site conducted

  Select

• Employee Name

• incident date and time

  Date

• Manager

• Was anyone hurt as a result of the incident, if yes please use the Accident initial response check list.

  Yes

  No

• Please switch over to Accident initial response check list

• Summary of incident

• Time of Incident

  Date

• Please take photos of scene

  Media

• Has the scene been altered since the incident

  Yes

  No

• Why was the scene altered

• Exact location of incident

• Activity in work area at time of incident

• Witnesses to incident

  Yes

  No

• Are statements being collected

  Yes

  No

• Condition of work place

  Good

  Fair

  Poor

• Please describe the reason why

• Name of supervisor of area

• Was Equipment/ MHE being used or in use during incident

  Yes

  No

• List the equipment/ MHE being used including fleet number or Serial number

• Has the Equipment/MHE been isolated

  Yes

  No

• If no please explain why not

• Please take photo of piece equipment

  Media

• Has the operator's authorisation to operate been revoked

  Yes

  No

• If no please explain why

• Was Hampton knight Called to site

  Yes

  No

• If No please explain why not

• Please upload Hampton knight outcome report to pack

• Please add any additional information or photographs that you feel is relevant to this incident

• Has a re-enactment taken place

  Yes

  No

• Reason why

Supporting comments

• Supporting Comments

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• Add signature

  Sign