SSF 017 Incident / Near-Miss Report

• Job Number

• Site

  Select

• Conducted on

  Date

• Site Supervisor

• Location
  Address

Particulars of Incident

• What are you reporting

  Select Incident Near-Miss

  • Incident
  • Near-Miss

• What was the Date & Time of Incident?

  Date

• Who were the Person(s) involved?

  Sign

• Where did it happen? (include building number/name, floor level, etc. where appropriate).

• Description of events (Take photographs if applicable)

• Details of Tools, Equipment, Plant or Machinery

• What corrective action steps have been taken to reduce the potential for similar accidents/incidents?

Report Sign-Off

• Add signature

  Sign

• C. G. Comley & Sons Limited T/A Comley Demolition. Registered office: Southern Way, Rye Common, Odiham, Hook, Hampshire, RG29 1HU. Telephone: 01256 702178. Email: comley@comleydemolition.co.uk Company Registration Number: 01672195