SPC Incident / Near Miss Report

• Document No.

• On completion of this form, Supervisors must place the incident on MY H&S Reporting System

INCIDENT

• Injury

  Yes

  No

• Near miss

  Yes

  No

Incident Details

• Depot location

  Blandford

  Exeter

  Poole

  Ryde

  Westbury

• Select date

  Date

• Employee of Spectrum Property Care?

  Yes

  No

  N/A

• Employer -

• Address where incident / near miss took place :-

• Where on that location / site?

• What operation was being carried out at the time?

• Brief description of damage :-

• Was a vehicle involved?

  Yes

  No

  N/A

• Registration number -

• Witness details (please provide name, address and phone number)

INJURED PERSON

• Person's name -

• Person's age -

• Sex

  Male

  Female

  Transgender

• Employer (if not as above) -

• Normal occupation -

• Was time lost through injury?

  Yes

  No

  N/A

• Date ceased work

  Date

• Was injured person authorised to be at the location?

  Yes

  No

• Was the injured person authorised to do that work?

  Yes

  No

• Length of service in years and months -

INJURY

• Please provide a general description of injury or condition :-

• Was the injured person taken to hospital?

  Yes

  No

  N/A

• Hospital name and location :-

• Was the injured person detained for more than 24 hours?

  Yes

  No

  N/A

DESCRIPTION OF INCIDENT / NEAR MISS

• Please describe the incident -

• Please provide any photos taken -

  Media

TYPE OF INCIDENT

• Select Contact with moving machinery Struck by moving / flying / falling object Struck by moving plant Struck against something fixed or stationary Handling, lifting, carrying Slip, trip or fall on same level Fall from height Trap, collapse or overturn Inhalation (asphyxiation / drowning) Exposure to or contact with harmful substances Fire or explosion Contact with electricity / electrical charge Injury by animal Physical assault by a person Road traffic accident Environmental Other type of incident

  • Contact with moving machinery
  • Struck by moving / flying / falling object
  • Struck by moving plant
  • Struck against something fixed or stationary
  • Handling, lifting, carrying
  • Slip, trip or fall on same level
  • Fall from height
  • Trap, collapse or overturn
  • Inhalation (asphyxiation / drowning)
  • Exposure to or contact with harmful substances
  • Fire or explosion
  • Contact with electricity / electrical charge
  • Injury by animal
  • Physical assault by a person
  • Road traffic accident
  • Environmental
  • Other type of incident

Declaration that the details provided are correct.

• Person affected or person reporting incident

  Sign

FM-04-39a