Visionstream NZ Near Hit/Miss Incident Report

• Document No.

• VPL NEAR HIT/MISS REPORT

• Prepared by

• Conducted on

  Date

WHAT IS A NEAR HIT/MISS?

• A near hit/miss is any unplanned event that could have had the potential for injury, ill health, damage or other loss. Unsafe working conditions, unsafe employee work habits, improper use of equipment or use of malfunctioning equipment have the potential to cause work related injuries.
  It is everyone's responsibility to report and/or correct these potential accidents/incidents immediately.
  

HOW DO I REPORT A NEAR HIT/MISS?

• You have 4 options to report a Near Hit/Miss:
  1. Call 0800 333 008 or 09 3521111, select option 8 (available 24/7) or
  2. Email a Near Hit/Miss Incident report to vplseqnz@visionstream.co.nz or
  3. Submit a Near Hit/Miss Incident report to a VPL representative or
  4. Submit your report here using iAuditor and email it to vplseqnz@visionstream.co.nz

INFORMATION REQUIRED

• Select date and time of potential incident/hazard :

  Date
• Select location of potential incident/hazard:
  Address

• Description of potential incident/hazard (What happened?)

• Description of potential injury, ill health, damage or other loss (What harm could have happened?)

• Attach any supporting documents/photos:

  Media

SELECT A CATEGORY DESCRIPTION

• Human

• Environment

• Vehicle/Plant/Equipment

• Underground Services

• If the potential incident/hazard involved an underground service, please select which one:

  Select Gas Electrical Water Sewer Stormwater Telecommunications

  • Gas
  • Electrical
  • Water
  • Sewer
  • Stormwater
  • Telecommunications

• If the potential incident/hazard involved an underground service, please select how:

  Utility plan incorrect (to actual location of service)

  Location marks incorrect (to actual location of service)

  Permit instructions not followed

  Other:

• If other, enter here:

• If an asbuilt is provided, utility service deviations will be notified to the appropriate Asset Owner.

PREVENTATIVE ACTIONS:

• List any immediate action taken to make the area safe or eliminate reoccurrence.

• What would have made it safer?